Form 10-10161 Veteran Assessment

VHA Homeless Programs - Project CHALENG (Community Homelessness Assessment, Local Education and Networking Groups) for Veterans

VHA Homeless Programs_Project CHALENG_Veteran Survey_2022

Veteran Survey

OMB: 2900-0843

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2022 CHALENG Survey -- Veteran

OMB Control Number: 2900-0843

Estimated Burden Avg: 6 minutes

Expiration Date: September 30, 2021


Identification:

  1. In which branch of the armed services did you serve?

  • Army

  • Navy

  • Marine Corps

  • Air Force

  • Coast Guard

  • National Guard/Reserve


  1. Where are you living now?

  • Literally Homeless (on streets, in shelter, in car)

  • Emergency Housing

  • Transitional Housing (Grant and Per Diem housing, VA Domiciliary, or community contract housing

  • Permanent subsidized housing (including HUD-VASH and Section 8)

  • Unsubsidized housing (private apartment/house/condominium)


Please only answer these questions if you answered question #2 with “Literally Homeless.” All other Veterans should skip questions 2(a) and 2(b).


2(a) Which of the following options best describes how long you have been homeless?

  • 0-3 months

  • 4-6 months

  • 7-12 months

  • 13-24 months

  • More than 24 months


2(b) Have you had four or more episodes of homelessness in the past three years?

  • Yes

  • No


  1. What gender do you identify as?

  • Male

  • Female

  • Transgender Male

  • Transgender Female

  • Gender Non-conforming



  1. What is your age?

  • Less than 25

  • 25-34

  • 35-44

  • 45-54

  • 55-64

  • 65-74

  • 75-84

  • 85+


5a. What race do you most strongly identify with?

  • American Indian or Alaska Native

  • Asian

  • Black or African American

  • Native Hawaiian or Other Pacific Islander

  • White

  • Don’t Know


5b. What ethnicity do you most strongly identify with?

  • Non-Hispanic/Non-Latino

  • Hispanic/Latino

  • Don’t Know


  1. How many dependents under the age of 18 are residing with you?

  • 0

  • 1

  • 2

  • 3

  • 4 or more


  1. Are you currently enrolled in the VA?

  • Yes

  • No

  • Unsure


  1. Is your housing in any way at risk (do you have trouble making mortgage payments, or are your housing plans uncertain)?

  • Yes

  • No


  1. Do you live in a rural or frontier community?

  • Yes

  • No


Please tell us in your own words: What is the most important resource/service that could help end your homelessness now, or if you are formerly homeless, what is the most important resource that will prevent you from being homeless in the future?



Based on your experience as a Veteran experiencing homelessness or former homelessness, please help us understand how well your needs are being met. Within the past 3 months (or 90 days) how well are your needs being met in the following:


Never

Met

Shape1


Always

Met

N/A

Housing

O

O

O

O

O

  1. Emergency/immediate Shelter

O

O

O

O

O

  1. Transitional Living Facility and Halfway House

O

O

O

O

O

  1. Long-term Permanent Housing

O

O

O

O

O

  1. Registered Sex Offender Housing

O

O

O

O

O

  1. Affordable Housing

O

O

O

O

O

  1. Eviction Prevention Services

Never

Met

Shape2


Always

Met

N/A

Treatment Services

O

O

O

O

O

  1. Medical Services

O

O

O

O

O

  1. Services for Emotional or Psychiatric Problems

O

O

O

O

O

  1. Substance Abuse Treatment

O

O

O

O

O

  1. HIV/AIDS Testing and Treatment

O

O

O

O

O

  1. Eye Care and Glasses

O

O

O

O

O

  1. Personal Hygiene (shower, haircut, etc.)

O

O

O

O

O

  1. Elder Healthcare and Resources

O

O

O

O

O

  1. Health and Wellness (preventing illness and prolonging life through diet, exercise and self care)

O

O

O

O

O

  1. Treatment for Dual Diagnosis

O

O

O

O

O

  1. Case Management

O

O

O

O

O

  1. Military Sexual Trauma

O

O

O

O

O

  1. Gender Specific Health Care Provider Availability






  1. Dental Care:






How would you describe the health of your teeth and gums?






O Excellent






O Very good






O Good






O Fair






O Poor

Never

Met

Shape3


Always

Met

N/A

Income/Benefits Services

O

O

O

O

O

1. VA Disability/Pension

O

O

O

O

O

2. Supplemental Security Income (SSI) and Social Security Disability (SSD)

O

O

O

O

O

3. Money Management and Budgeting

O

O

O

O

O

4. Food

O

O

O

O

O

5. Clothing

O

O

O

O

O

6. Family Reconciliation Assistance/Family Counseling

O

O

O

O

O

7. Move-In Assistance

O

O

O

O

O

8. Utility Assistance

O

O

O

O

O

9. Transportation

O

O

O

O

O

10. Child Care


Never

Met

Shape4


Always

Met

N/A

Legal Assistance

O

O

O

O

O

1. Legal Assistance to Help Restore a Driver’s License

O

O

O

O

O

2. Financial Guardianship

O

O

O

O

O

3. Re-Entry Services for Incarcerated Veterans

O

O

O

O

O

4. Legal Assistance for Child Support Issues

O

O

O

O

O

5. Legal Assistance for Outstanding Warrants and Fines

O

O

O

O

O

6. Legal Assistance to Expunge a Criminal Record

O

O

O

O

O

7. Legal Assistance for Credit Issues/Debt Collection/Bankruptcy

O

O

O

O

O

8. ADA issues with rental housing (i.e. ramps for wheelchair access, accommodation of service animals)

O

O

O

O

O

9. Domestic Violence/Protection Orders

O

O

O

O

O

  1. Tax Issues

O

O

O

O

O

11. Discharge Upgrade Appeals

O

O

O

O

O

12. Family Law (i.e. divorce, child custody)

Never

Met

Shape5


Always

Met

N/A

Education/Job Services

O

O

O

O

O

1. Education

O

O

O

O

O

2. Job Training

O

O

O

O

O

3. Finding a Job or Getting Employment

O

O

O

O

O

4. Vocational Rehabilitation (a process that enables people with functional, psychological, developmental, cognitive, or emotional impairments or health conditions to overcome barriers to accessing, maintaining, or returning to employment)


Yes

No

Don’t Know

Digital Access

O

O

O

Do you use the internet, at least occasionally?




How often do you access the Internet?

O Never

O At least once a day

O At least once a week but not every day

O At least once a month but less than once a week

O Less than once a year

O

O

O

Do you have a cell phone?

O

O

O

Do you have a smart phone?

O

O

O

Do you own a computer or laptop?







Not Accessible



Very Accessible

N/A

VA and Community Coordination

O

O

O

O

O

1. In general, how accessible do you feel VA services are to homeless Veterans in your community?

Not Able



Mostly Able

N/A


O

O

O

O

O

2. How able is the VA to coordinate services for homeless Veterans?

Not Aware



Mostly Aware

N/A


O

O

O

O

O

3. How aware of Veterans’ needs and resources are Community Homeless Agencies?


The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 6 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and respond to questions asked. Veteran satisfaction is used to gauge Veteran perceptions of VA services, as well as expectations and desires. The results of this survey/assessment will lead to improvements in the quality of service delivery by helping to shape the direction and focus of services and the Veteran experience. Participation in this survey is voluntary, and failure to respond will have no impact on benefits to which you may be entitled.

Thank you for your participation in the CHALENG survey! If you would like more information or if you have any concerns, please contact the Call Center for Homeless Veterans: http://www.va.gov/homeless/nationalcallcenter.asp | 1-877-4AID VET (1-877-424-3838)

VA Form 10-10161

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AuthorBlue-Howells, Jessica
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File Created2021-10-19
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