Form 10-10162 Provider Survey

2022 CHALENG Survey -- Provider

OMB Control Number: 2900-0843

Estimated Burden Avg: 6 minutes

Expiration Date: September 30, 2021

Respondent Identification

1. Which of the following best describes your reasons for taking the CHALENG survey?

• I work for the VA

• I work for another Federal Agency

• I work for a state or local government agency or a community-based homeless provider

• I am an interested member of the community

2. Did you complete a CHALENG survey last year?

Yes

No

Provider’s Identification

Please only answer if you indicated that you work for the VA

1a. Which of the following best describes your organization and affiliation?

• Veterans Health Administration Central Office

• Veterans Benefit Administration Central Office

• VA National Cemetery Administration Central Office

• VISN

• VA Medical Center or Outpatient Clinic

• VA Regional Office

• Vet Center

• VA Cemetery

Please only answer if you indicated that you work for a Federal agency other than the VA.

1b. Which of the following best describes your organizational affiliation?

• Department of Housing and Urban Development

• Department of Labor

• United States Interagency Council on Homelessness

• Department of Health and Human Services

• Department of Education

• Department of Defense

• Social Security Administration

• Department of Agriculture

• Department of Justice

• Department of Transportation

• Department of Interior

• Other

Please only answer if you DO NOT work for the federal government.

1c. Which of the following best describes your organizational affiliation?

• State Department of Veterans Affairs

• State or Local Health and Human Services Agency

• State or Local Mental Health Department

• State or Local Correctional Agency or Law Enforcement Organization

• Other State or Local Government Agency

• Veterans Services Organization

• Non-profit Community-based Organization

• For-profit Community-based Organization

• Other

Please tell us in your own words: What is the most important resource/service that could help end Veteran homelessness in your community?

Based on your experience serving homeless Veterans, please help us understand how well the needs of Veterans are being met. Within the past 3 months (or 90 days) how well are Veterans’ needs being met in the following areas:

Never Met			Always Met	N/A	Housing
O	O	O	O	O	Emergency/immediate Shelter
O	O	O	O	O	Transitional Living Facility and Halfway House
O	O	O	O	O	Long-term Permanent Housing
O	O	O	O	O	Registered Sex Offender Housing
O	O	O	O	O	Affordable Housing
O	O	O	O	O	Eviction Prevention Services
Never Met			Always Met	N/A	Treatment Services
O	O	O	O	O	Medical Services
O	O	O	O	O	Services for Emotional or Psychiatric Problems
O	O	O	O	O	Substance Abuse Treatment
O	O	O	O	O	HIV/AIDS Testing and Treatment
O	O	O	O	O	Eye Care and Glasses
O	O	O	O	O	Personal Hygiene (shower, haircut, etc.)
O	O	O	O	O	Elder Healthcare and Resources
O	O	O	O	O	Health and Wellness (preventing illness and prolonging life through diet, exercise and self care)
O	O	O	O	O	Treatment for Dual Diagnosis
O	O	O	O	O	Case Management
O	O	O	O	O	Military Sexual Trauma
O	O	O	O	O	Gender Specific Health Care Provider Availability
					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			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					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		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					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)
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. Customer satisfaction is used to gauge customer perceptions of VA services, as well as customer 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 patient 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 10-10162