Appendix R: Housing Assistance Questionnaire

OMB Control # 0970 – XXXX

Expiration Date: XX/XX/XXXX

Appendix R: Housing Assistance Questionnaire

Housing Application and Search Assistance Questionnaire

This information is also being collected to inform the evaluation of the Family Unification Program (FUP) 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 [RELEVANT AGENCY OR AGENCIES]. All the information you provide will be kept private to the extent permitted by law

This questionnaire will ask about the services that you have provided to the family related to housing application, voucher issuance, signing a lease, and move in. Please only fill out this form if the family has either: (1) Received a voucher and signed a lease or (2) Been denied a voucher.

Family’s Child Welfare ID:
Project ID:
Client Name:
Case Manager/Worker’s Name:
Organization:
Today’s Date:

Service provision

Have you been providing services to the family around the housing application and signing a lease?  Yes No

Has any other agency/organization been providing services to the family around the housing application and signing a lease?

 Yes, please specify the organization: ________________________________ No

How many times did you meet with the family during this process? _________________

Is this more often than you typically meet with a client?  More  Less  Same

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 5 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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What APPLICATION assistance have you provided or coordinated (Please Select All that Apply):
☐	Help filling out the housing application
☐	Help getting necessary documents for the housing application
☐	Help finding transportation to the housing intake and voucher briefing
☐	Attend housing intake or voucher briefing with the family
☐	Help interacting with the housing authority
☐	Help paying off money owed to the housing authority
☐	Help submitting an appeal after voucher denial
☐	Other, please specify:
What HOUSING SEARCH assistance have you provided or coordinated (Please Select All that Apply):
☐	Help paying off money owed to other landlords
☐	Help paying off money owed to utilities
☐	Help with a credit review
☐	Help searching for an apartment or house
☐	Taking families on neighborhood tours
☐	Taking families on unit viewings
☐	Provide a list of landlords who accept vouchers or who have worked with the housing authority in the past
☐	Providing landlord introductions
☐	Provide a list of available properties
☐	Help paying application fees
☐	Help filling out a rental application
☐	Help interacting/negotiating with landlords
☐	Advice on overcoming personal history barriers
☐	Coaching on how to talk to landlords
☐	Provide or coordinate transportation to look at housing units
☐	Provide a list of other organizations that can help families find units
☐	Referrals to local fair housing and equal opportunity offices
☐	Focused help around finding housing in low-poverty neighborhoods
☐	Other, please specify:

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What assistance have you provided or coordinated around SIGNING A LEASE (Please Select All that Apply):
☐	Help reading a lease
☐	Help paying first month’s rent
☐	Help paying security deposit
☐	Help paying first month’s utilities
☐	Help paying for furniture and household items
☐	Help moving into the apartment/house
☐	Counseling on compliance with rental lease requirements
☐	Counseling on compliance with HCV program participant requirements
☐	Other, please specify:

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