Appendix O: Housing Status Form

OMB Control # 0970 – XXXX

Expiration Date: XX/XX/XXXX

Appendix O: Housing Status Form

Housing Status Form

This information is being collected to assess the housing status of families being served by [CHILD WELFARE OR REFERRING AGENCY] to help identify families eligible for the Family Unification Program (FUP). For families referred to FUP, the information collected on this form can be transferred directly to the FUP Referral Form. This information is also being collected to inform the evaluation of the Family Unification Program being conducted by a research team at the Urban Institute, Chapin Hall at the University of Chicago and Child Trends. This information will be used to inform the US Department of Health and Human Services Administration for Children and Families (HHS ACF) and the US Department of Housing and Urban Development to improve the administration of the FUP program. This form should be completed by staff at [CHILD WELFARE OR REFERRING AGENCY]. All the information you provide will be kept private to the extent permitted by law.

This form collects housing information aligned with definitions of homelessness and housing instability created by the US Department of Housing and Urban Development’s (HUD). Agencies may reformat the form and add (but not remove) items as needed,

Status Assessment Date:__________________________________

Child Welfare ID:_______________________________

Location of current residence (e.g. zip code, to be adapted to conform with each site’s housing authority requirements): ___________________________________

Worker name:________________________ Supervisor name:_______________________

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to evaluate the effectiveness of the Family Unification Program. Public reporting burden for this collection of information is estimated to average two minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Michael Pergamit at mpergamit@urban.org.

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Child Welfare Involvement

Client has an open DCF child welfare case: Y ☐ N ☐

Case type (current): ☐ Reunification ☐Family Preservation

Current Living Situations

Where is the family currently living?

☐ Private house/apartment of own

☐ With friends or relatives

☐ In place not designed for sleeping accommodation for human beings (e.g. car, park, abandoned building, bus or train station, airport, camping ground)

☐ Emergency shelter

☐ Transitional housing

☐ Hotel or motel

☐ Residential substance abuse treatment*

☐ Hospital (includes psychiatric hospitals) *

☐ Jail/incarcerated*

☐ Other, specify*:

*If client is in an institution (Residential SA treatment, psychiatric hospital, jail/incarcerated):

Will the client have access to stable housing upon exit? Y ☐ N ☐

What is their discharge date:____/____/______ (MMDDYYYY)

Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U)

Living in dilapidated housing

The unit does not provide safe and adequate shelter and in its present

condition endangers the health, safety or well-being of the family. Y ☐ N ☐ U ☐

The unit has one or more critical defects, or a combination of intermediate

defects in sufficient number or extent to require considerable repair or

rebuilding. Y ☐ N ☐ U ☐

Family is living in substandard housing

Housing unit does not have operable indoor plumbing. Y ☐ N ☐ U ☐

Housing unit does not have a usable flush toilet inside the unit for the

exclusive use of a family. Y ☐ N ☐ U ☐

Housing unit does not have a usable bathtub or shower inside the unit

for the exclusive use of a family. Y ☐ N ☐ U ☐

Housing unit does not have electricity, or has inadequate or unsafe

electrical service. Y ☐ N ☐ U ☐

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Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U) [CONTINUED]

Housing unit does not have a safe or adequate source of heat. Y ☐ N ☐ U ☐

Housing unit should, but does not, have a kitchen. Y ☐ N ☐ U ☐

Housing unit has been declared unfit for habitation by an agency or

unit of government or in its present condition otherwise endangers the

health, safety, or well-being of the family. Y ☐ N ☐ U ☐

Family Is homeless

An individual or family with a primary nighttime residence that is a

public or private place not designed for or ordinarily used as a regular

sleeping accommodation for human beings, including a car, park,

abandoned building, bus or train station, airport, or camping ground. Y ☐ N ☐ U ☐

An individual or family living in a supervised publicly or privately

operated shelter designated to provide temporary living arrangements

(including congregate shelters, transitional housing, and hotels and

motels paid for by charitable organizations or by federal, State, or

local government programs for low-income individuals). Y ☐ N ☐ U ☐

An individual who is exiting an institution where he or she resided for

90 days or less and who resided in an emergency shelter or place not

meant for human habitation immediately before entering that

institution. Y ☐ N ☐ U ☐

An individual or family who will imminently lose their primary

nighttime residence provided that: (1) The primary nighttime

residence will be lost within 14 days of the date of application for

homeless assistance (2) No subsequent residence has been identified

(3) The family lacks the resources or support networks, e.g., family,

friends, faith-based or other social networks, needed to obtain other

permanent housing. Y ☐ N ☐ U ☐

An individual or family who is fleeing or is attempting to flee, domestic

violence, dating violence, sexual assault, stalking, or other dangerous or

life-threatening conditions that relate to violence against the individual

or a family member, including a child, that has either taken place within

the individual’s or the family’s primary nighttime residence or has made

the individual or family afraid to return to their primary nighttime

residence; AND has no other residence; AND lacks the resources or

support networks, e.g. family, friends, and faith-based or other social

networks, to obtain other permanent housing. Y ☐ N ☐ U ☐

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Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U) [CONTINUED]

Family is living in an overcrowded unit

The family is separated from its child (or children) and the parent(s) are

living in otherwise standard housing unit, but, after the family is

re-united, the parents’ housing unit would be overcrowded for the entire

family and would be considered substandard. (A unit is considered to be

overcrowded if the head of household has to share a bedroom with an

individual that is not their spouse or significant other or there are more

than 2 people per bedroom.) Y ☐ N ☐ U ☐

The family is living with its child (or children) in a unit that is

overcrowded for the entire family and this overcrowded condition may

result in the imminent placement of its child (or children) in out-of-home

care. Y ☐ N ☐ U ☐

Family is living with a household member that could result in

placement of child or delay of discharge from placement.

Family is living in a unit where the presence of a household member

with certain characteristics (i.e., conviction for certain criminal

activities) would result in the imminent placement of the family’s

child, or children, in out-of-home care; or the delay in the discharge

of the child, or children, to the family from out-of-home care. Y ☐ N ☐ U ☐

Family is living in a unit not accessible to disabled child(ren)

FUP Referral

If you choose to refer this family to the Family Unification Program (FUP), you can copy the items on this form directly to the FUP Referral form or attach it to the FUP Referral form.

Family is living in housing not accessible to the family’s disabled

child or children due to the nature of the disability. Y ☐ N ☐ U ☐

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