Form 1122-XXX Safe Housing Needs Assessment

Homeless Shelter/Housing Provider Questions (FINAL post stakeholder feedback)
(Introduction Q3 answers F)

1. How knowledgeable is your organization about the scope of the domestic and/or sexual
violence programs in your community (i.e. knowledgeable of services offered/understands
process of accessing services)?
a.
Very knowledgeable
b.
Somewhat knowledgeable
c.
A little knowledgeable
d.
Not at all knowledgeable
e.
I don’t know
(if answered b (somewhat), c (A little) or D (not at all) to Q1
1a. What are the barriers to knowing the scope of the domestic and/or sexual violence programs
in your community? (Select all that apply)
a) Not enough staff capacity
b) System too confusing
c) Not enough communication with domestic and/or sexual violence organizations
d) Lack of trust
e) Other (please explain)
2. Does your program have relationships with staff from domestic and/or sexual violence
programs?
a) Yes
b) No
c) No, but other homeless/housing organizations do.
d) Not sure
If answered “yes” to Q2
2a. How did you build these relationships with staff from domestic and/or sexual violence
programs?
3. For survivors needing both, domestic and/or sexual violence, as well as homeless/housing
services and resources, does your organization have any agreements with domestic and/or sexual
violence programs to coordinate domestic and/or sexual violence and housing services?
a. Yes (Please describe how this agreement works)
b. No (How do survivors continue receiving the necessary services from the domestic
and/or sexual violence system?)
c. Not sure
4. Is there a Taskforce/Working Group in your community that focuses on domestic and/or
sexual violence and homeless/housing issues?
a. Yes
b. No

c. No, but we are interested in participating in a collaboration like this
d. In development
e. Not sure

(if answered a (yes) to Q4
4a. Does staff at your organization participate in the Taskforce/Working Group?
a. Yes
b. No
c. No, but staff at other domestic and/or sexual violence organizations participate

If answered a (yes) Q4a
5. How helpful is the Taskforce/Working Group in addressing issues impacting survivors’ access
to housing in your community?
a. Very helpful
b. Somewhat helpful
c. A little helpful
d. Not at all helpful
e. Not sure
If answered (very helpful) or (somewhat helpful) in Q5
5a. What are the desired outcomes for this Taskforce/Working Group? (Select all that apply)
a. Build partnerships between domestic and/or sexual violence organizations
and homeless/housing agencies
b. Develop more permanent housing options for survivors
c. Coordinate advocacy efforts such that survivors’ concerns (i.e. safety and
confidentiality) are included in housing/homeless policy and programs
d. Advocate for local housing protections for survivors
e. Increase housing providers’ (including the PHA) awareness of housing
protections for survivors
f. Increase safety for survivors in the homeless system
g. Help facilitate or further implement a coordinated entry system that
incorporates the domestic and/or sexual violence housing system
h. Other (please explain)
If answered (not at all helpful) in Q5
5b. If the Taskforce/Working group is not helpful in addressing issues impacting domestic and/or
sexual violence and homelessness/housing, please explain why.
Topic Area: Assessment & Safety Planning

1. For domestic and/or sexual violence survivors, your organization’s intake assessment includes
questions about: (Select all that apply)
a.
b.
c.
d.

Current level of danger from other people (e.g., restraining orders, history of
domestic violence, threats from others).
History of trauma (e.g., physical, emotional or sexual abuse, neglect, loss,
domestic/community violence, combat, past homelessness).
None
Not sure

2. When your organization conducts the intake assessment, survivors are in a safe location to
disclose (i.e. private space, separate from partner if they present together).
a. Yes
b. No
c. Sometimes (please explain)
d. Not sure
3. Does your organization do safety planning (i.e. discussing safety during a violent incident, in
her/his residence, safety with a protection order and/or on the job) with survivors?
a. Yes
b. No
c. Sometimes (please explain)
d. Not sure
(if responds “yes” to Q3
3a. Individualized safety plans include the following: (Select all that apply)
a. Safety during a violence incident (i.e. using a code/safe word with family/friends,
teaching children when to call 911, identify escape route/safe place to go)
b. Safety when preparing to leave (i.e. identifying safe person to leave money, extra
keys, important documents with)
c. Safety in my own residence (i.e. safety measures a survivor can use - change
locks on doors/windows, install/enhance security system)
d. Safety with a protection order (i.e. who to leave copies of the protection order
with, who to inform of the protection order)
e. Safety on the job and in public (i.e. informing employer/HR/security supervisor,
plan for schedule adjustment/modify routine)
f. Other (please explain)
1. Have your organization’s policies and procedures been examined with survivor safety in
mind?
a. Yes
b. No
c. Not sure
if answered “yes” Q4
4a. Was that process advised by domestic and/or sexual violence content experts?

a. Yes
b. No
c. Not sure
5. Does your organization have a transfer or relocation policy so that a survivor can be moved to
a new unit if their location becomes unsafe?
a. Yes (Please describe the transfer policy)
b. No
c. Not sure
6. Is your organization equipped to provide the intake assessment for survivors with Limited
English Proficiency (i.e. in languages other than English)?
a. Yes (In which languages_______________________)
b. No (Please explain how you address this)
c. Not sure

Topic Area: Training
1. Have staff at your organization received training on domestic and/or sexual violence?
a. Yes
b. No
c. Not sure
(if answered A (yes) to Q1
1a. How frequently does your organization receive training from domestic and/or sexual violence
programs?
a. Monthly
b. Quarterly
c. Yearly
d. As needed/with new staff
e. Not sure
if answered “Monthly” “Quarterly” “Yearly” or “As needed/with new staff” to Q1a
2. What are the topics for these trainings? (Select all that apply)
a. Domestic violence 101
b. Sexual violence 101
c. Safety planning
d. Confidentiality
e. Domestic and/or Sexual Violence Screening Assessments
f. Understanding legal housing protections for survivors (federal, state, local)
g. Services for marginalized communities (i.e. older victims, culturally and linguistically
appropriate services)
h. Trauma Informed Care
i. Survivor-Centered Voluntary Service Models

j. Unique barriers to housing faced by survivors (i.e. lack of affordable housing, lack of
available safe housing, inclusiveness and access for LGBTQ survivors)
k. Other (please explain)
if answered B (no) to Q1
3. Why do the homeless/housing organizations not receive trainings from domestic and/or sexual
violence programs on a regular basis? (Select all that apply)
a. Not a priority
b. Not enough time
c. Too much staff turnover to make an impact
d. Other (please explain)
4. What training topics/issues would you want to receive training on from a domestic and/or
sexual violence program? (Select all that apply)
a. Domestic violence 101
b. Sexual violence 101
c. Safety planning
d. Domestic and/or Sexual Violence Screening Assessments
e. Understanding legal housing protections for survivors (federal, state, local)
f. Services for marginalized communities (i.e. older victims, culturally and linguistically
appropriate services)
g. Trauma Informed Care
h. Survivor-Centered Voluntary Service Models
i. Unique barriers to housing faced by survivors (i.e. lack of affordable housing, lack of
available safe housing, inclusiveness and access for LGBTQ survivors)
j. Other (please explain)
5. Does your organization provide training for domestic and/or sexual violence programs?
a. Yes
b. No
c. Not sure
If answers A (yes) to Q5
5a. How frequently does your organization provide training for domestic and/or sexual violence
programs?
a. Monthly
b. Quarterly
c. Yearly
d. As requested or needed/with new staff
e. Not sure
if answered “Monthly” “Quarterly” “Yearly” or “As needed/with new staff” to Q5a
6. What are the topics for the trainings your organization provides to domestic and/or sexual
violence programs? (Select all that apply)
a. Understanding the homeless/housing system
b. Understanding the scope and work of specific homeless/housing agencies

c.
d.
e.
f.
g.
h.

Coordinated Entry & Assessment
Building relationships with landlords
Services for marginalized communities (i.e. culturally appropriate services)
Housing first
Rapid Rehousing
Other (please explain)

if answered B (No) to Q5
6a. Why doesn’t your organization provide trainings on a regular basis to domestic and/or sexual
violence programs? (Select all that apply)
a. Not a priority
b. Not enough time
c. Too much staff turnover to make an impact
d. Lack of funding
e. Other (please explain)
7. What training topics/issues do you believe domestic and/or sexual violence agencies should be
trained on? (Select all that apply)
a. Understanding the homeless/housing system
b. Understanding the scope and work of specific homeless/housing agencies
c. Coordinated Entry & Assessment
d. Building relationships with landlords
e. Services for marginalized communities (i.e. culturally and linguistically appropriate
services)
f. Housing first
g. Rapid Rehousing
h. Other (please explain)
Topic Area: Housing First, Rapid Re-housing
1. I believe my community has adopted a Housing First strategy to help people access
permanent housing quickly (an average of 30 days or less) regardless of their barriers.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
2. I believe the homeless service organizations in our community believe that all survivors of
domestic and/or sexual violence are housing ready immediately without needing time to
transition back into housing.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree

e. I don’t know
3. I believe the domestic and/or sexual violence service programs in our community feel that
all survivors of domestic violence are housing ready immediately without needing time to
transition back into housing.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
4. I believe domestic and/or sexual violence programs in my community accept clients
regardless of their sobriety, use of substances, completion of treatment, and participation in
services.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
5. I believe homeless service organizations in my community accept clients regardless of their
domestic and/or sexual violence history, sobriety, use of substances, completion of treatment,
and participation in services.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. It may vary depending on the type of housing (i.e. low barrier shelters vs. Rapid
Rehousing programs). Please explain.
f. I don’t know
6. I believe domestic and/or sexual violence programs in my community seldom reject clients
on the basis of lack of income, poor credit/financial history, poor/lack of rental history and minor
criminal convictions.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
If answers disagree or strongly disagree to Q6
6a. Why do you disagree or strongly disagree that domestic and/or sexual violence programs
seldom reject clients on the basis of lack of income, poor credit/financial history, poor/lack of
rental history and minor criminal convictions?

7. I believe homeless services in my community seldom reject clients on the basis of domestic
and/or sexual violence status, lack of income, poor credit/financial history, poor/lack of rental
history and minor criminal convictions.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
If answered strongly agree or agree to Q7
7a. Why do you strongly agree or agree that homeless services in your community seldom reject
clients on the basis of domestic and/or sexual violence status, lack of income, poor
credit/financial history, poor/lack of rental history and minor criminal convictions?
8. I believe homeless service in my community seldom reject clients on the basis of limited
English proficiency.
a.
b.
c.
d.
e.

Strongly Agree
Agree
Disagree
Strongly Disagree
I don’t know

9. I believe homeless service in my community seldom reject clients on the basis of immigration
status.
a.
b.
c.
d.
e.

Strongly Agree
Agree
Disagree
Strongly Disagree
I don’t know

10.
Does your community have CoC-wide standards that promote a Housing First Approach
to all interventions and services?
a. Yes
b. No
c. I don’t know
11.
What training does your community need on Housing First practices? (please select all
that apply)
a. Housing First 101
b. A more specific training (please explain_______)
c. Don’t need training
d. I don’t know

12. Does your community have low-barrier emergency shelter or crisis housing that allows
survivors of domestic and/or sexual violence to be accepted regardless of their sobriety and
income?
a. Yes
b. No
c. I don’t know
13. Which populations and subpopulations does the transitional housing in your community
serve? (Select all that apply)
a. Domestic violence and/or sexual violence
b. Youth
c. Substance abuse
d. Other (please explain)
14. Does your community need technical assistance to re-tool (i.e. modify) some of its
transitional housing programs to allow survivors of domestic and/or sexual violence
access/prioritization for other housing program models?
a. Yes
b. No
c. I don’t know
15. Does your community need technical assistance to re-tool (i.e. modify) some or all of its
emergency shelter or crisis housing to allow survivors of domestic and/or sexual violence to be
accepted regardless of their sobriety, income, or family configuration?
a. Yes
b. No
c. I don’t know
16. I believe the programs serving survivors of domestic and/or sexual violence use a voluntary
services approach.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
17.
I believe our community has sufficient Rapid Re-Housing (RRH) resources in place to rehouse survivors of domestic and/or sexual violence quickly when they become homeless.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
18.
I believe our community can re-house survivors of domestic and/or sexual violence in an
average of 30 days or less.
a. Strongly Agree

b.
c.
d.
e.

Agree
Disagree
Strongly Disagree
I don’t know

19. On average, how many days does it take to re-house survivors of domestic and/or sexual
violence in your community? (______)
20.
Our biggest challenges in implementing RRH that works quickly and sustains people in
their housing are: (Select all that apply)
a. Lack of effective landlord engagement practices
b. Lack of staff that specialize in housing identification and landlord engagement
c. Lack of availability of pet-friendly housing or emergency/crisis pet sheltering
d. Lack of funds for implementing RRH to scale
e. Lack of standards around administering financial assistance
f. Lack of training in best practices in RRH
g. Lack of effective case management to help people stay in housing once it is obtained
h. Lack of community-based support services
i. Lack of standards around program practice and performance outcome measures between
programs
j. Lack of knowledge or buy-in about the effectiveness of the RRH program model
k. Other (please explain______________)
21.
I believe our community is successful at engaging and recruiting landlords to rent to
survivors of domestic and/or sexual violence.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
22.
I believe RRH programs in my community offer survivors of domestic and/or sexual
violence choice in units, and within the limitations of a client’s income help locate units that are
desirable and safe from the survivor’s perspective.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
23. I believe RRH programs in my community offer supportive and voluntary services to
survivors of domestic and/or sexual violence who are rapidly re-housed.
a. Strongly Agree
b. Agree
c. Disagree

d. Strongly Disagree
e. I don’t know
24.
I believe our community’s programs have a strong understanding of the core components
of a best practice rapid re-housing program.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
25.
RRH providers in my community believe safety planning is an essential part of contact
with all survivors.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
26.
RRH providers in my community have established protocols for staff safety when
conducting voluntary visits with survivors of domestic and/or sexual violence.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
27. RRH providers in my community are knowledgeable about and trained in, trauma-informed
approaches.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
28. If a survivor of domestic and/or sexual violence requires more or less financial assistance,
RRH providers in my community have flexibility to shorten or lengthen the duration of
assistance.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. I don’t know
29. RRH providers in my community have access to flexible funding sources to pay for
expenses critical to re-housing survivors of domestic and/or sexual violence not covered by
federal funding (i.e. buying groceries, car repairs, etc).

a.
b.
c.
d.
e.

Strongly Agree
Agree
Disagree
Strongly Disagree
I don’t know

30. What is the biggest challenge your community has in housing survivors of domestic and/or
sexual violence in 30 days or less?

TOPIC AREA: Coordinated Entry and Assessment
Q1. Does your community have a Coordinated Entry System (CES)?
(A Coordinated Entry System (CES) is a process developed to ensure that all people
experiencing a housing crisis have fair and equal access and are quickly identified, assessed for,
referred, and connected to housing and assistance based on their strengths and needs. A CES
handles assessment/screening of consumer need, data entry, referrals, and, potentially, program
admissions, and prevention and diversion services as well.)
Yes
No
Not sure
If answers a (Yes) to Q1
Q2: Does your community have a Coordinated Entry System (CES) that includes domestic
and/or sexual violence programs?
a. Yes
b. No
c. Not sure
if answered “no” to Q2
Q2a: Why doesn’t your community have a CES that includes domestic and/or sexual violence
programs? (Select all that apply)
a. Lack of coordination within the homeless service community
b. Lack of trust within the homeless services community
c. Lack of coordination with the domestic and/or sexual violence system
d. Lack of trust with domestic and/or sexual violence system
e. Lack of relationships with domestic and/or sexual violence system
f. Lack of knowledge (i.e. how to set up a coordinated entry system with domestic and/or
sexual violence system)
g. Data entry and confidentiality concerns with utilization of HMIS system
h. Lack of resources
i. Separate domestic violence and/or sexual violence and Homeless/ Housing funding
streams are not conducive to coordination
j. A CES that includes domestic and/or sexual violence programs is in the process of being

developed.
if answered “yes” to q2
Q2b: What kind of CES does your community have for domestic and/or sexual violence
survivors?
a. Single point of entry for all (for homeless services, including survivors)
b. Multiple points of entry for all (for homeless services, including survivors)
c. Domestic and/or sexual violence providers have independent/parallel system
d. In development of domestic and/or sexual violence provider independent/parallel system
e. In development of single point of entry for all (for homeless services, including
survivors)
f. In development of multiple points of entry for all (for homeless services, including
survivors
g. Other (please explain)
(if answered C (“independent/parallel system”) Q2b
Q3a: What is the entry point to the independent/parallel domestic and/or sexual violence
system? (Select one of the following)
a. Intake center (centralized physical location)
b. Multiple entry points (i.e. various organizations have the ability to make referral
to the system)
c. Hotline (can include 2-1-1)
d. Other (please expand)
e. Not sure
(
Q3b: How is housing availability made known within the independent/parallel domestic
and/or sexual violence system? (Select all that apply)
a. Shared availability list updated by shelter and/or housing programs
b. Coordinated through hotline
c. Managed through another coordinating body (i.e. coalition, local government agency) [
Please expand ___]
d. Shared database
e. Other (please expand ____)
f. Not sure
Q3c: Is there only one standardized assessment used to determine housing eligibility within the
independent/parallel domestic and/or sexual violence system?
a. Yes (which assessment tool is used (i.e. VI-SPDAT) ________)
b. No, (please explain how housing eligibility is determined)
c. Not sure
(if answered A “single point of entry” Q2b
Q4a: What is the entry point within the single point of entry system?
a. Intake center (centralized physical location)
b. Community-wide hotline (can include 2-1-1)

c. Not sure
d. Other (Please explain _____)
Q4b: The single point of entry is coordinated by: (Select all that apply)
a. A local government agency
b. Homeless program or homeless coalition /Continuum of Care
c. Not Sure
d. Other (Please explain _____)
Q4c: How are survivors’ needs assessed (i.e. housing, safety, confidentiality and privacy) and
triaged within the single point of entry system? (Select all that apply)
a. An intake assessment is used to screen for domestic and/or sexual violence, along
with other housing needs
b. Housing placement is prioritized for domestic and/or sexual violence survivors
c. There is a dedicated domestic and/or sexual violence specialist at the centralized
intake center or hotline to assess survivor needs
d. There is no specialized domestic and/or sexual violence assessment/triage protocol
e. There are various precautions and measure in place to protect survivor
confidentiality and safety
f. Other (Please explain _______)
g. Not sure
if answered E “in development of single point of entry” to Q2b
Q5a. What will the single entry point be within the single point of entry system?
a. Intake center (centralized physical location)
b. Community-wide hotline (can include 2-1-1)
c. Other (please explain _____)
d. Not sure
Q5b: What agency (or agencies) will coordinate the centralized intake within the single point of
entry system? (Select all that apply):
a. Local government agency
b. Homeless program or homeless coalition
c. Other (please explain _____)
d. Not sure
Q5c: How will domestic violence and/or sexual violence survivors’ needs be assessed (i.e.
housing, safety, confidentiality and privacy) and triaged within the single point of entry
system? (Select all that apply)
a. An intake assessment is used to screen for domestic and/or sexual violence, along with
other housing needs
b. Housing placement is prioritized for domestic and/or sexual violence survivors
c. There is a dedicated domestic and/or sexual violence specialist at the centralized intake
center or hotline to assess survivor needs
d. There is no specialized domestic and/or sexual violence assessment/triage protocol
e. There are various precautions and measure in place to protect survivor confidentiality and

safety
f. Other (Please explain _______)
g. Not sure
if answers B “multiple points of entry” to Q2b
Q6a: How is housing availability made known within the multiple points of entry system?
(Select all that apply)
a. Shared availability list updated by shelter and/or housing programs
b. Coordinated through hotline
c. Managed through another coordinating body (i.e. domestic and/or sexual violence
coalition, local government agency) [Please explain____]
d. Other (please expand ____)
e. Not sure
i
Q6b. Is there only one standardized assessment used to determine housing eligibility within
the multiple points of entry system?
a. Yes (which assessment tool is used (i.e. VI-SPDAT) ________)
b. No (how is housing eligibility determined throughout the system?)
c. Not sure
Q6c: How are survivors’ needs assessed (i.e. housing, safety, confidentiality and privacy)
and triaged? (Select all that apply)
a. One (shared) intake assessment is used to screen for domestic and/or sexual violence,
along with other housing needs
b. Each entry point uses its own intake assessment to screen for domestic and/or sexual
violence, along with other housing needs
c. Housing placement is prioritized for domestic and/or sexual violence survivors
d. There is a dedicated victim specialist (staff with expertise in domestic and/or sexual
violence) at one or more of the non-victim specific entry points
e. There are no specialized domestic and/or sexual violence assessment/triage protocols
at the multiple entry points
f. There are various precautions and measures in place to protect survivor
confidentiality and safety
g. Not included at this point
h. Not sure
if answered A (single point of entry), B (multiple points of entry) or C (domestic and/or sexual
violence providers have an independent/parallel system) to Q2b
Q7a. Coordinated entry works well in my community.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree

e. Neither agree nor disagree
f. I don’t know
Q7b. My community struggles with coordinated entry, particularly as it relates to safety and
confidentiality considerations for domestic and/or sexual violence survivors.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. Neither agree nor disagree
f. I don’t know
i
Q7c: Domestic and/or sexual violence survivors who access your community’s coordinated
entry system have the option to withhold consent to share data via any electronic database
without feeling that their housing options will be compromised.
a. Yes
b. No
c. Not sure
If answers a (yes) to Q7c
Q8: Survivors offered the option of withholding consent, ultimately give consent to share
personal information because they feel that their housing options would be compromised.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. Neither agree nor disagree
f. I don’t know
if answered A (single point of entry), B (multiple points of entry) or C (domestic and/or sexual
violence providers have an independent/parallel system) to Q2b
Q7d. Coordinated entry staff members in my community are adequately equipped to assess
when an individual or a family would benefit from housing in a domestic violence/sexual
assault program rather than a general homeless assistance provider.
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. Neither agree nor disagree
f. I don’t know
Q7e: During Coordinated Entry assessment, survivors are able to make their own decisions (i.e.
survivor choice is respected) regarding which programs or resources they want to access so they
have a range of options (i.e. whether to access domestic and/or sexual violence shelter/housing
or programs available through the homeless system).
a. Strongly Agree

b.
c.
d.
e.
f.

Agree
Disagree
Strongly Disagree
Neither agree nor disagree
I don’t know

i
Q7f. Coordinated entry staff members have access to the necessary (i.e. knowledge of programs,
scope of work, etc) to make referrals to domestic and/or sexual violence agencies when needed
(including when requested by domestic and/or sexual violence survivors)?
a. Strongly Agree
b. Agree
c. Disagree
d. Strongly Disagree
e. Neither agree nor disagree
f. I don’t know
i
Q7g. Does the coordinated entry process help the community prioritize services based on
vulnerability and severity need to ensure that domestic and/or sexual violence survivors who
need immediate access to safe housing options receive assistance in a timely manner?
a. Yes
b. No
c. Not sure
Q7h. How are domestic and/or sexual violence survivors triaged within the coordinated
entry system when they have multiple needs (i.e. older victims, Limited English Proficiency)?
TOPIC AREA: HMIS
1. Does your organization conduct an informed consent process for domestic and/or sexual
violence survivors prior to sharing private identifying information?
a. Yes
b. No
c. Not sure
2: Does your CoC and/or Coordinated Entry System (CES) have an HMIS data entry opt-in
policy?
a. Yes
b. No
c. Not sure
3. Has your CoC and/or CES developed an HMIS-comparable database for domestic and/or
sexual violence programs that allows measurement of the same metrics tracked in the
homeless/housing system?
a. Yes

b. No
c. Not sure
4. To what extent does your CoC understand the federal laws/regulations around victim service
providers (includes domestic and/or sexual violence organizations), HMIS and comparable
databases?
a. A lot
b. Somewhat
c. A little
d. Not at all
e. I don’t know
5. Does your CoC recognize that Victim Service Providers (including domestic and/or sexual
violence organizations) are prohibited from entering client data into HMIS?
a. Yes
b. No
c. Not sure
6. Has the CoC and domestic and/or sexual violence programs implemented a viable comparable
database to HMIS?
a. Yes
b. No
c. Not sure
TOPIC AREA: Compliance with federal, state and local legal protections (think VAWA,
Fair Housing Act, state/local: anti-discrimination, eviction, lock changes, etc)
Q1: If a domestic and/or sexual violence survivor discloses the violence during your
intake/assessment, is the survivor asked to meet additional requirements (i.e. having a protection
order, police report) before being accepted into your program?
a. Yes
b. No
c. Not sure
If answered “yes” to Q1
Q1a. What additional requirements are survivors asked to meet before being accepted into your
program? (Select all that apply)
a. Protection order
b. Counseling
c. Police report
d. Other (please explain)
Q2. Does your organization serve the following domestic and/or sexual violence survivors?
(Select all that apply)
a. The survivor has limited English proficiency (LEP)(i.e. has another language as their
primary language and may need a translator).
b. The survivor is a Native person.

c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.

The survivor is Deaf.
The survivor is a person of color.
The survivor has an active addiction.
The survivor has a criminal history.
S/he is a survivor of sex trafficking.
S/he is or perceived to be lesbian, gay, bi-sexual or transgender.
The survivor has a male child over the age of 12.
S/he is a survivor of sexual violence (non-intimate partner violence).
S/he is a survivor over the age of 50
S/he is a survivor of teen dating violence.
The survivor's family, regardless of the age of children or composition of the family
seeking shelter.
The survivor is an immigrant (documented).
The survivor is an immigrant (undocumented).
The survivor has an animal companion/pet (not for reasonable accommodation).
The survivor is disabled.
The survivor has a mental health issue.
The survivor has poor credit and/or poor rental history.
The survivor opts out of sharing confidential information due to safety and/or privacy
issues.
The survivor is male.
Other (please explain).
None of the above

(if answered “none” to Q2
Q2a. If your organization does not serve domestic and/or sexual violence survivors, why? (Select
all that may apply)
a. Once a domestic and/or sexual violence survivor discloses her/his status as a survivor, we
refer them to a domestic and/or sexual violence program
b. The survivors listed in the previous question do not seek our services
c. Our organization does not accept individuals fleeing domestic or sexual violence because
we are not equipped to handle those clients
d. Other (please explain)
Q3: What kind of challenges are you aware of domestic and/or sexual violence survivors facing
when it comes to staying in/keeping shelter and/or housing? (Select all that apply)
(Shelter and/or housing includes: homeless shelters/housing programs, domestic violence
shelters/housing programs, public housing, Section 8, Subsidized housing, private housing
(apartment or house)
a. Shelter and/or housing provider refuses to restore or improve security and safety
measures (i.e. repair locks, windows, doors, and other physical features of residence)
b. Shelter and/or housing provider refuses to change the locks
c. Not being able to move because of the cost of breaking a lease
d. Eviction or threat of eviction for calling police or other emergency services

e. Threats of eviction because of domestic and/or sexual violence-related disruptions
f. Threats of shelter stay termination for not complying with program rules (participating in
services, back by curfew, signing in/out of facility, etc.).
g. Unable to secure safe housing (transitional or permanent) before the shelter’s length of
stay deadline.
h. Unable to afford housing.
i. Other (please expand ______)
Q4. Does your organization work with the Public Housing Authority (PHA) to help survivors
seeking lease bifurcation and/or emergency transfer?
(Bifurcation means the survivor is allowed to remain in place and the batterer will be taken off a
lease without their permission.)
(Emergency Transfer allows survivors to transfer to another available and safe dwelling unit.)
(A Public Housing Authority (PHA) is a local housing agency that receives HUD Federal
funds to manage federally subsidized housing for low-income residents at rents they can afford.)
a. Yes
b. No
c. Not sure
if answer a (yes) Q4
Q4a: Please rate how effective the PHA is in helping survivors seeking lease bifurcation and/or
emergency transfer?
a. Very Effective
b. Somewhat Effective
c. A little Effective
d. Not at all Effective
e. I don’t know
Q5: Does your organization work with the PHA to create and expand housing options for
survivors (i.e. can include affordable housing)?
a. Yes (Please explain)
b. No
c. Not sure
d. We have no PHA in our community
If answered is “yes” to Q5
5a. How does your organization collaborate with your local PHA to create more safe housing
options? (Select all that applies):
The PHA prioritizes all survivor applications by placing them at the top of the waiting list
The PHA has a local voucher program specifically for domestic and/or sexual violence
survivors who are exiting domestic and/or sexual violence survivor shelters or are homeless
as a result of domestic and/or sexual violence.
PHA provides vouchers or helps fund in some way housing that your organization operates

PHA provides permanent housing vouchers for survivors exiting your program
Other (please explain)
Q6: Does your organization work with private landlords to assist survivors seeking privately
owned housing?
Yes (please expand on your relationship with private landlords)
No
Not sure
Q7: To the best of your knowledge, how familiar is your organization with federal housing laws
and protections for domestic and/or sexual violence survivors? Please rank your familiarity with
each law:

Q8: To the best of your knowledge, how has your organization utilized each of the following
federal laws and protections in advocacy efforts with survivors? (Select all that apply)

Q9. Do your domestic and/or sexual violence local and/or state laws provide housing

protections to survivors (i.e. fair housing protection, eviction protection)?
a. Yes
b. No
c. Not sure
if answered “yes” to Q9
Q9a. To what extent does your organization understand the domestic and/or sexual violence
local and/or state laws that provide housing protections to survivors (i.e. fair housing protection,
eviction protection)?
A lot
Somewhat
A little
Not at all
I don’t know