Form 10-10161 CHALENG Survey - Veteran

2025 CHALENG Survey -- Veteran

OMB Control Number: 2900-0843

Estimated Burden Avg: 6 minutes

Expiration Date: XX/XX/20XX

Identification:

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

Army Navy Marine Corps

Air Force Coast Guard National Guard/Reserve

2. Where are you living now?

• Homeless - sheltered (in shelter)

• Homeless - unsheltered (on streets, public encampment, 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 “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

3. What gender do you identify as?

Male	Female
Transgender Male	Transgender Female Gender Non-conforming

4. 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

• Middle Eastern or North African

• 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

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

0 1 2

3 4 or more

6. Are you currently enrolled in the VA?

Yes

No

Unsure

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

• Yes

• No

6. 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			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 O O	Eviction Prevention Services Preparation for Natural Disaster/ Extreme Emergency Assistance with safe firearms storage
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	Complementary and Alternative Medicine (acupuncture, herbal medicine, meditation)
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)

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? Do you use the Internet to access VA services? Do you use any phone apps for your health care?

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?

VA Burden Statement: 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 control number for this project is 2900-0843, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 6 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please refer to OMB Control No. 2900-0843 in any correspondence. Do not send your completed VA Form 10-10161 to this email address.

Privacy Notice: No Personally Identifiable Information (PII) or Protected Health Information (PHI) will be collected or maintained, and therefore the Privacy Act does not apply to this survey. However, your responses will be kept private and confidential to the extent provided by law. The results of this survey will be used to assess and plan services that meet the needs of homeless Veterans. Participation in this survey is voluntary, and your failure to respond will have no impact on any benefits to which you are 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