DSS - AIDS Supportive Housing / HOPWA Report Overview

Report Period Enter Report Start Date: Enter Report End Date (Plus 1 Day): 10/1/10 7/1/12

Providers Reporting Information in this Report CT HMIS Reporting Demo - HOPWA(942) CT HMIS Reporting Demo - HOPWA - SubProvider(1149)

Special Notes Part 2: Section 2 Part 3: Section 1. Part 3: Section 1. b. Part 3: Section 2. Part 3: Section 3. Part 2: C. Part 2: C : Lines 13 - 14 Utilization Beneficiaries include those living with HIV/AIDS AND all associated members of their household receiving HOPWA housing assistance Area Median Income (AMI) is taken from the Head of Household when a family. Excludes those with a Housing Assistance type of "Receiving NO HOPWA housing assistance" Housing placement assistance activities numbers are taken from values provided by report prompts. Utilization rate calculated by looking at number of Beds or Units used in period vs available capacity. Unmet need numbers are taken from values provided by report prompts. In the case of families with more than 1 HIV/AIDS + persons, only one person will be counted in section 1. Individuals

Part 2: Grantee Narrative and Performance Assessment

1. Service Area:
1. Total number of households that have unmet housing needs c. Housing Facilities, such as community residences, SRO dwellings, other housing facilities Not Provided by HMIS Not Provided by HMIS

2. Assessment of Areas Unmet Needs for HOPWA-eligible Households

1. Total number of households that have unmet housing needs = 15

From Item 1, identify the number of households with unmet housing needs by type of housing assistance. a. Tenant-Based Rental Assistance (TBRA) b. Short-Term Rent, Mortgage and Utility payments (STRMU) Assistance with rental costs Assistance with mortgage payments Assistance with utility costs c. Housing Facilities, such as community residences, SRO dwellings, other housing facilities = = = = = = 5 9 4 3 2 1

Part 3: Summary Overview of Grant Activities

Date Check: Total for Section 1a should be equal Section1b row 18.

Section 1. Individuals

a. Total HOPWA eligible individuals living with HIV/AIDS

Individuals Served with Housing Assistance Number of individuals with HIV/AIDS who received HOPWA housing assistance Total Number 26

HOPWA Eligible Person: A low-income person with HIV/AIDS who qualifies the household for HOPWA assistance. This person may be considered Head of Household. When the APR asks for information on eligible individuals, report on this person only. Where there is more than one person with HIV/AIDS in the household, the additional PWA(s), would be considered a beneficiary(s).

b. Prior Living Situation.

Total HOPWA Eligible Individuals Served with Housing Assistance 24

1.

Category Continuing to receive HOPWA support from the prior operating year

New Individuals who received HOPWA Housing Assistance support during Operating Year 2. 3. 4. 5. Place not meant for human habitation (such as a vehicle, abandoned building, bus/train/subway station/airport, or outside) Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher) Transitional housing for homeless persons Total number new individuals who received HOPWA Housing Subsidy Assistance with a Prior Living Situation that meets HUD definition of homelessness (Sum of Rows 2 4) Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod Rehab) Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non-psychiatric facility) Foster care home or foster care group home Jail, prison or juvenile detention facility Rented room, apartment, or house* House you own* Staying or living in someone elses (family and friends) room, apartment, or house* Hotel or motel paid for without emergency shelter voucher Other Dont Know or Refused* TOTAL of HOPWA Eligible Individuals( Sum of Rows 1 and 5-17) 0 0 0

0 0 0 0 0 0 0 0 1 0 0 0 1 26 0

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Note: Items with Asterisk are combined picklist values of similar nature Individual Clients with NULL Prior Living Situation (ERROR)

c. Homeless Individuals Summary

In Chart c., indicate the number of HOPWA eligible individuals reported as homeless in Chart b., Row 5 who are also identified as homeless Veterans and/or meet the definition for Chronically Homeless (See Definition section of APR). The totals in Chart c. do not need to equal the total in Chart b., Row 5. Domestic Violence Category Veteran(s) Chronically Homeless Survivor(s) HOPWA eligible individuals served with HOPWA Housing Subsidy Assistance 0 0 0 No Data 0 0 0 Note: The totals in Chart c. do not need to equal the total in Chart b., Row 5.

Part 3: Section 1 - Detail

Entry / Exit Data Entry Exit Inactive No No No 10/1/10 No No No No No No 10/1/10 No No No No No No 10/30/10 10/1/10 10/1/10 10/1/10 No No No No No No No No No No No Entered During Report Period EnteredPrior EnteredCurrent EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredCurrent EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior EnteredPrior HH Relat. None None None None None None None None None None None None None None None None None None None None Self Self Self None None None U.S. Military Veteran?(220) Chron. Homeless No

Client ID 132472 138819 138822 138824 143453 143454 143466 143503 143504 143506 143508 143509 143512 143513 143515 143519 143525 143530 143531 143532 143886 143891 143895 144858 144859 144860

Entry 11/4/09 12/21/10 4/21/09 4/21/09 2/17/10 11/2/09 3/1/10 6/15/08 10/15/09 11/3/09 12/1/09 1/1/10 2/1/10 4/1/10 5/1/10 7/1/10 2/17/10 12/1/09 10/31/10 9/1/10 3/1/10 2/1/10 4/1/10 9/30/10 1/1/10 2/1/10

Exit 1/3/11 12/21/10

Group ID None None None None None None None None None None None None None None None None None None None None 126761 126764 126769 None None None

DV

Living Sit.

HIV/AIDS Yes

Yes (HUD) Emergency shelter, including hotel or Yes (HUD) for with emergency shelter voucher(HUD) motel paid Yes Yes No (HUD) Owned by client, with housing subsidyNo (HUD) (HUD) No (HUD) Emergency shelter, including hotel or No (HUD) for with emergency shelter voucher(HUD) motel paid No Yes No (HUD) Emergency shelter, including hotel or Yes (HUD) for with emergency shelter voucher(HUD) motel paid Yes Yes Yes (HUD) Rental by client, no housing subsidy (HUD) Yes (HUD) Yes Yes Yes (HUD) Emergency shelter, including hotel or No (HUD) for with emergency shelter voucher(HUD) motel paid Yes Yes No (HUD) Emergency shelter, including hotel or Yes (HUD) for with emergency shelter voucher(HUD) motel paid No Yes No (HUD) Staying or living in a family member's No (HUD) room, apartment or house (HUD) No Yes No (HUD) Place not meant for habitation inclusive of 'non-housing service site(outreach programs only)'(HUD) No (HUD) No Yes No (HUD) Emergency shelter, including hotel or No (HUD) for with emergency shelter voucher(HUD) motel paid No Yes No (HUD) Transitional housing for homeless persons (including homeless youth) Yes No (HUD) No (HUD) No (HUD) Permanent housing for formerly homeless persons(such as SHP, S+C,YesSRO Mod Rehab)(HUD) No (HUD) No or No (HUD) Psychiatric hospital or other psychiatric facility (HUD) No (HUD) No (HUD) Foster care home or foster care groupNo (HUD) home (HUD) No (HUD) Jail, prison or juvenile detention facility (HUD) No (HUD) No (HUD) Owned by client, no housing subsidy (HUD) No (HUD) No (HUD) Other (HUD) No (HUD) Don't Know (HUD) No (HUD) X No (HUD) No (HUD) No (HUD) No No No No No No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No (HUD) Substance abuse treatment facility or No (HUD) (HUD) No detox center

No (HUD) Rental by client, no housing subsidy (HUD) No (HUD) No (HUD) Owned by client, no housing subsidy (HUD) No (HUD) No (HUD) Rental by client, no housing subsidy (HUD) No (HUD) No (HUD) Rental by client, no housing subsidy (HUD) No (HUD) No (HUD) Rental by client, no housing subsidy (HUD) No (HUD) No (HUD) Owned by client, no housing subsidy (HUD) No (HUD)

Part 3: Summary Overview of Grant Activities

Date Check: The total reported in Section 2a Row 1 should match the total in Part 3, Section 1, Chart a.

Section 2. Beneficiaries
a. Total Number of HOPWA Beneficiaries Served with Housing Assistance
Individuals and Families Served with Housing Assistance 1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA housing subsidy assistance (equals the number of HOPWA Eligible Individuals reported in Part 3A,Section 1,Chart a, Row 7) 2. Number of other persons residing with the above eligible individuals in HOPWA-assisted housing 3. Number of ALL other persons not diagnosed as HIV positive who reside with the HOPWA eligible individual identified in Row 1 and who benefited from the HOPWA housing subsidy 4. TOTAL Number of ALL Beneficiaries Served with HOPWA Housing Subsidy Assistance (Sum of Rows 1, 2, & 3) Total Number

26 3 3 32

b. Age and Gender

HOPWA Eligible Individuals (Chart a, Row 1) A. Male 1. 2. 3. 4. 5. Under 18 18 to 30 years 31 to 50 years 51 years and Older Subtotal (Sums of Rows 1-4) 2 9 5 2 18 B. Female 0 5 3 1 11 C. Trangender M to F 0 0 0 0 0 D. Trangender F to M 0 0 0 0 0 E. Total (Sum of Columns A-D) 2 14 8 3 29

All Other Beneficiaries (Chart a, Rows 2 and 3) A. Male 6. 7. 8. 9. 10. Under 18 18 to 30 years 31 to 50 years 51 years and Older Subtotal (Sums of Rows 1-4) 0 0 0 0 0 B. Female 0 2 0 0 2 C. Trangender M to F 0 0 0 0 0 D. Trangender F to M 0 0 0 0 0 E. Total (Sum of Columns A-D) 0 2 0 0 2

Total Beneficiaries (Chart a, Row 4) 10. TOTAL (Sum of Rows 5 & 10) 18 13 0 0 31

Part 3: Summary Overview of Grant Activities

c. Race and Ethnicity*

HOPWA Eligible Individuals Total Beneficiaries Served with Housing Assistance 2 1 7 1 9 All Other Beneficiaries Total Beneficiaries Served with Housing Assistance 0 0 1 0 0

1. 2. 3. 4. 5. 6.

Category American Indian/ Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White American Indian/ Alaskan Native & White Asian & White

Total Beneficiaries also identified as Hispanic or Latino 1 0 4 0 0

Total Beneficiaries also identified as Hispanic or Latino 0 0 0 0 0

1 1

0 0

0 0

0 0

7. 8.

Black/African American and White 9. American Indian/ Alaskan Native & Black/African American 10. Other Multi-Racial

1 See totals for 10C on tab: Part 3.2 Detail B

1 See totals for 10D on tab: Part 3.2 Detail B

0 See totals for 10C on tab: Part 3.2 Detail C

0 See totals for 10D on tab: Part 3.2 Detail C 1 1 0 1 1

11. Column Totals (Sum 3 of Rows 1-10) 29 10 ERROR: Primary and Secondary Race are the same (remove or change secondary race answer). ERROR: Don't Know / Refused ERROR: Null Primary Race ERROR: Null Ethnicity

Section 3. Households
Household Area Median Income.
Percentage of Area Median Income 1. 0-30% of area median income (extremely low) 2. 31-50% of area median income (very low) 3. 51-80% of area median income (low) 4. Total (Sum of Rows 1-3) ERROR: AMI above 80% Households Served with HOPWA Housing Assistance 8 2 11 21 5

Date Check:

The total reported above in Part 3. Section 3 Row 4 should match the total in Part 3, Section 1, Chart a.

Part 3: Section 2 - Detail for HOPWA Eligible

Race & Ethnicity by row/category American Indian / Alaskan Black / Afr. Amer. Native Amer / Black

Asian

Hawaiian

White

Indian / White

Asian/White

Black / White

Other

Client ID

1a Non-H

1b Hisp. 1

2a Non-H 1

2b Hisp. 0

3a Non-H 7

3b Hisp. 4

4a Non-H 1

4b Hisp. 0

5a Non-H 9

5b Hisp. 0

6c Non-H 1

6d Hisp. 1

7c Non-H 1

7d Hisp. 0

8c Non-H 2

8d Hisp. 1

9c Non-H 1

9d Hisp. 1

10c Non-H 4

10d Hisp. 2

Totals:

132472

138819

138821

138822

138824

143453

143454

143466

143503

Part 3: Section 2 - Detail for HOPWA Eligible

Race & Ethnicity by row/category American Indian / Alaskan Black / Afr. Amer. Native Amer / Black

Asian

Hawaiian

White

Indian / White

Asian/White

Black / White

Other

Client ID

1a Non-H

1b Hisp. 1

2a Non-H 1

2b Hisp. 0

3a Non-H 7

3b Hisp. 4

4a Non-H 1

4b Hisp. 0

5a Non-H 9

5b Hisp. 0

6c Non-H 1

6d Hisp. 1

7c Non-H 1

7d Hisp. 0

8c Non-H 2

8d Hisp. 1

9c Non-H 1

9d Hisp. 1

10c Non-H 4

10d Hisp. 2

Totals:

143504

143506

143508

143509

143512

143513

143515

143519

143525

Part 3: Section 2 - Detail for HOPWA Eligible

Race & Ethnicity by row/category American Indian / Alaskan Black / Afr. Amer. Native Amer / Black

Asian

Hawaiian

White

Indian / White

Asian/White

Black / White

Other

Client ID

1a Non-H

1b Hisp. 1

2a Non-H 1

2b Hisp. 0

3a Non-H 7

3b Hisp. 4

4a Non-H 1

4b Hisp. 0

5a Non-H 9

5b Hisp. 0

6c Non-H 1

6d Hisp. 1

7c Non-H 1

7d Hisp. 0

8c Non-H 2

8d Hisp. 1

9c Non-H 1

9d Hisp. 1

10c Non-H 4

10d Hisp. 2

Totals:

143530

143531

143532

143886

143891

143892

143893

143895

144858

Part 3: Section 2 - Detail for HOPWA Eligible

Race & Ethnicity by row/category American Indian / Alaskan Black / Afr. Amer. Native Amer / Black

Asian

Hawaiian

White

Indian / White

Asian/White

Black / White

Other

Client ID

1a Non-H

1b Hisp. 1

2a Non-H 1

2b Hisp. 0

3a Non-H 7

3b Hisp. 4

4a Non-H 1

4b Hisp. 0

5a Non-H 9

5b Hisp. 0

6c Non-H 1

6d Hisp. 1

7c Non-H 1

7d Hisp. 0

8c Non-H 2

8d Hisp. 1

9c Non-H 1

9d Hisp. 1

10c Non-H 4

10d Hisp. 2

Totals:

144859

144860 29

Part 3: Section 2 - Detail for Beneficiaries

Race & Ethnicity by row/category American Indian / Alaskan Black / Afr. Amer. American Indian / White Black Afr. Amer. / White American Indian / Black

Asian

Hawaiian

White

Asian / White

Other

Client ID

1a Non-H

1b Hisp. 0

2a Non-H 0

2b Hisp. 0

3a Non-H 1

3b Hisp. 0

4a Non-H 0

4b Hisp. 0

5a Non-H 0

5b Hisp. 0

6c Non-H 0

6d Hisp. 0

7c Non-H 0

7d Hisp. 0

8c Non-H 1

8d Hisp. 1

9c Non-H 0

9d Hisp. 0

10c Non-H 1

10d Hisp. 0

Totals:

138820

143887

143896 3

Part 3: C. Performance and Expenditure InformationC. Performance and Expenditure Information

1. Performance and Expenditure Information by Activity Type Housing Development (Construction and Stewardship of [1] HOPWA Assistance Outputs: Facility-Based Housing) Households 1. Tenant-Based Rental Assistance 4 2a. Permanent Housing Facilities: Received Operating Subsidies/Leased units 2b. Households in transitional/short-term facilities that receive operating subsidies 3a. Permanent Housing Facilities: Capital Development Projects placed in service during the operating year 3b. Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year 4. Short-term Rent, Mortgage, and Utility Assistance 5. Permanent Housing Placement Services 6. Adjustment for duplication (subtract) 7. TOTAL Housing Assistance Recieved NO HOPWA housing assistance 8. Facility-Based units being developed with capital funding but not yet opened (identify units of housing planned) 9. Stewardship units subject to 3- or 10year use periods 10. TOTAL Housing Development ERROR: Housing Assistance Type is NULL

[2] Amount of HOPWA Funds Expended Not Provided by HMIS

Not Provided by HMIS

Not Provided by HMIS

Not Provided by HMIS

2 5 0 0 15 6

Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS

Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS 0

Part 3: C. Performance and Expenditure Information

Supportive Services 11a. Supportive Services provided by project sponsors also delivering HOPWA housing assistance (as reported in Part 5 D, 1a) 11b. Supportive Services provided by project sponsors serving households who have other housing arrangements (as reported in Part 5, D, 1b) 12. Adjustment for duplication (subtract) 13. TOTAL Supportive Services

[1] HOPWA Assistance Outputs: Households

[2] Amount of HOPWA Funds Expended

15

Not Provided by HMIS

6 0 21 [1] Outputs: Number of Households 0 0 [1] HOPWA Assistance Outputs: Households

Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS [2] Outputs: Amount of HOPWA Funds Expended Not Provided by HMIS Not Provided by HMIS [2] Amount of HOPWA Funds Expended Not Provided by HMIS

Housing Information Services 14. Housing Information Services 16. TOTAL Housing Placement Assistance Grant Administration and Other Activities 17. Resource Identification to establish, coordinate and develop housing assistance resources 18. Technical Assistance (if approved in grant agreement) 19. Project Outcomes/Program Evaluation (if approved in grant agreement) 20. Grantee Administration (maximum 3% of total of HOPWA grant) 21. Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded) 22. Other Activity (if approved in grant agreement). Specify: 23. TOTAL Grant Administration and Other Activities Total Expended 24. TOTAL Expenditures (Sum of Rows 6, 9, 12, 16 & 23)

Not Provided by HMIS Not Provided by HMIS

Not Provided by HMIS

Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS [2] Amount of HOPWA Funds Expended Not Provided by HMIS

Part 4: Section 1
Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability (Permanent Housing and Facilities)
In Column [1], report by type the total number of households that received HOPWA housing subsidy assistance. In Column [2], enter the number of households continuing to access each type of HOPWA housing subsidy assistance into the following year. In Column [3], report the housing status of all households that exited the program. Note: Refer to the destination codes that appear in Part 6: Appendix: Worksheet on Determining HOPWA Outcomes and Connections with HMIS. A. Permanent Housing Assistance [A] Permanent Housing Assistance [1] Total Number of Households Receiving Housing Assistance [2] Assessment: Number of Households Continuing with this Housing (per plan or expectation for next year) Missing "Plan or Expectati on" [3] Assessment: Number of Exited Households and Housing Status [4] HOPWA Client Outcomes

1 Emergency Shelter/Streets

Unstable Arrangements Temporarily Stable, with Reduced Risk of Homelessness

2 Temporary Housing 3 Private Housing

0 0 0 0 0 0 0 0 0

Tenant-based Rental Assistance

4 Other HOPWA 5 Other Subsidy 6 Institution 7 Jail/Prison 8 Disconnected/Unknown 9 Death 1 Emergency Shelter/Streets

Stable/Permanent Housing (PH)

Unstable Arrangements Life Event Unstable Arrangements Temporarily Stable, with Reduced Risk of Homelessness

2 Temporary Housing

0 0 0 0 1 0 0 0

Permanent Supportive Housing Facilities/Units

3 Private Housing

4 Other HOPWA 5 Other Subsidy 6 Institution 7 Jail/Prison 8 Disconnected/Unknown 9 Death

Stable/Permanent Housing (PH)

Unstable Arrangements Life Event

B. Transitional Housing Assistance

1 Emergency Shelter/Streets

Unstable Arrangements Temporarily Stable, with Reduced Risk of Homelessness

2 Temporary Housing 3 Private Housing

0 0 1 0 0 1 0 0

Transitional/Sho rt term Support Facilities/Units

4 Other HOPWA 5 Other Subsidy 6 Institution 7 Jail/Prison 8 Disconnected/Unknown 9 Death

Stable/Permanent Housing (PH)

Unstable Arrangements Life Event

Part 4: Section 2. Prevention of Homelessness: Assessment of Client Outcomes on reduced risks of homelessness (Short-Term Housing Assistance)

Assessment of Households receiving STRMU Assistance

[1] STRMU Housing Assistance [2] Assessment of Housing Status [3] HOPWA Client Outcomes

Maintain private housing without subsidy (e.g. Assistance provided/completed and client is stable, not likely to seek additional support) Other Private Housing without subsidy Other HOPWA support (PH) Other housing subsidy (PH) Institution (e.g. residential and long-term care) Likely to maintain current housing arrangements, with additional STRMU assistance Transitional Facilities/Short-term (e.g. temporary or transitional arrangement) Temporary/Non-Permanent Housing arrangement (e.g. gave up lease, and moved in with family or friends but expects to live there less than 90 days) Emergency Shelter/street Jail/Prison Disconnected Death Still Enrolled

0 0
Stable/Permanent Housing (PH)

0 0 1 0 1
Temporarily Stable, with Reduced Risk of Homelessness

0 0 0 0 1 2
Life Event Still Ongoing (No Outcome) Unstable Arrangements

1a. Total number of those households that received STRMU Assistance in the prior operating year, that received STRMU assistance in the current operating year 1b. Total number of those households that received STRMU Assistance in the two (2 years ago) prior operating years, that received STRMU assistance in the current operating year

Not available from HMIS

Not available from HMIS

Part 4: Detail: By Household

Group ID 126761
Likely to maint. current housing w/add. STRMU

Client ID Household ID Entry Date

Exit Date

HOPWA Elligable Ind.

Housing Assistance Type Receiving NO HOPWA housing assistance

HUD Exit Destination

HOPWA Exit Category

Plans to continue ?

Is Dest. HOPWA PSH

143886

73434

3/1/10

Yes

Still Enrolled

Still Enrolled

No

Group ID 126764
Likely to maint. current housing w/add. STRMU

Client ID Household ID Entry Date

Exit Date

HOPWA Elligable Ind.

Housing Assistance Type Receiving NO HOPWA housing assistance

HUD Exit Destination

HOPWA Exit Category

Plans to continue ?

Is Dest. HOPWA PSH

143891

73435

2/1/10

Yes

Still Enrolled

Still Enrolled

No

Group ID 126769
Likely to maint. current housing w/add. STRMU

Client ID Household ID Entry Date

Exit Date

HOPWA Elligable Ind.

Housing Assistance Type Receiving NO HOPWA housing assistance

HUD Exit Destination

HOPWA Exit Category

Plans to continue ?

Is Dest. HOPWA PSH

143895

73436

4/1/10

Yes

Still Enrolled

Still Enrolled

No

Part 4: Detail: By Household Group ID Single Individuals: No Group ID

Likely to maint. current housing w/add. STRMU

Client ID Household ID Entry Date

Exit Date

HOPWA Elligable Ind.

Housing Assistance Type Short-term Rent, Mortgage, and Utility Assistance (STRMU) Permanent housing facilities developed with capital funds, and placed in service during the operatin

HUD Exit Destination Foster care home or foster care group home (HUD)

HOPWA Exit Category

Plans to continue ?

Is Dest. HOPWA PSH

138819

12/21/10

12/21/10

Yes

138824

4/21/09

10/1/10

Yes

Hospital (non-psychiatric) (HUD)

143453

2/17/10

Yes

Tenant-Based Rental Assistance (TBRA)

Still Enrolled

Still Enrolled

Yes

143466

3/1/10

Yes

Tenant-Based Rental Assistance (TBRA)

Still Enrolled

Still Enrolled

Yes

143503

6/15/08

Yes

Tenant-Based Rental Assistance (TBRA)

Still Enrolled

Still Enrolled

Yes

143504

10/15/09

Yes

Receiving NO HOPWA housing assistance

Still Enrolled

Still Enrolled

No

Part 4: Detail: By Household

Likely to maint. current housing w/add. STRMU

Client ID Household ID Entry Date

Exit Date

HOPWA Elligable Ind.

Housing Assistance Type Short-term Rent, Mortgage, and Utility Assistance (STRMU) Transitional/short-term facilities developed with capital funds, and placed in service during the op Transitional/short-term facilities that receive operating subsidies Permanent housing facilities developed with capital funds, and placed in service during the operatin

HUD Exit Destination

HOPWA Exit Category

Plans to continue ?

Is Dest. HOPWA PSH

143506

11/3/09

10/1/10

Yes

Deceased (HUD)

Yes

143508

12/1/09

Yes

Still Enrolled

Still Enrolled

No

143509

1/1/10

Yes

Still Enrolled

Still Enrolled

No

143512

2/1/10

Yes

Still Enrolled

Still Enrolled

No

143515

5/1/10

Yes

Tenant-Based Rental Assistance (TBRA)

Still Enrolled

Still Enrolled

No

143519

7/1/10

10/30/10

Yes

Short-term Rent, Mortgage, and Utility Assistance (STRMU) Transitional/short-term facilities developed with capital funds, and placed in service during the op

Hotel or motel paid for without emergency shelter voucher (HUD)

No

143525

2/17/10

10/1/10

Yes

Other (HUD)

No

Yes

Part 4: Detail: By Household

Likely to maint. current housing w/add. STRMU

Client ID Household ID Entry Date

Exit Date

HOPWA Elligable Ind.

Housing Assistance Type Transitional/short-term facilities that receive operating subsidies

HUD Exit Destination Jail, prison or juvenile detention facility (HUD)

HOPWA Exit Category

Plans to continue ?

Is Dest. HOPWA PSH

143530

12/1/09

10/1/10

Yes

No

143531

10/31/10

Yes

Receiving NO HOPWA housing assistance

Still Enrolled

Still Enrolled

No

144858

9/30/10

Yes

Short-term Rent, Mortgage, and Utility Assistance (STRMU)

Still Enrolled

Still Enrolled

Yes

144859

1/1/10

Yes

Receiving NO HOPWA housing assistance

Still Enrolled

Still Enrolled

Yes

144860

2/1/10

Yes

Short-term Rent, Mortgage, and Utility Assistance (STRMU)

Still Enrolled

Still Enrolled

Yes

Part 4: Section 3 Detail - Questions 1A to 1D

maintaining or establishing stable on-going housing Has contact with case manager/benefits counselor Successfully accessed or maintained qualification for sources of income.

Client ID

Entry Date

Exit Date

132472

11/4/09

1/3/11

138819

12/21/10

12/21/10

138822

4/21/09

138824

4/21/09

10/1/10

143453

2/17/10

143454

11/2/09

143466

3/1/10

143503

6/15/08

Housing Assistance Type lities that receive operating Permanent housing facisubsidies/lease d units Short-term Rent, Mortgage, and Utility Assistance (STRMU) lities that receive operating Permanent housing facisubsidies/lease d units Permanent housing facilities developed with capital funds, and placed in service during the operatin Tenant-Based Rental Assistance (TBRA) lities that receive operating Permanent housing facisubsidies/lease d units Tenant-Based Rental Assistance (TBRA) Tenant-Based Rental Assistance (TBRA)

contact with a primary health care provider

Has accessed and can maintain medical insurance/assistance

Obtained Employment

Yes

No

No

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

Yes

Yes

No

Yes

No

Yes

No

No

No

No

No

No

Yes

Part 4: Section 3 Detail - Questions 1A to 1D

maintaining or establishing stable on-going housing Has contact with case manager/benefits counselor contact with a primary health care provider Has accessed and can maintain medical insurance/assistance Successfully accessed or maintained qualification for sources of income.

Client ID

Entry Date

Exit Date

143506

11/3/09

10/1/10

143508

12/1/09

143509

1/1/10

143512

2/1/10

143513

4/1/10

143515

5/1/10

143519

7/1/10

10/30/10

143525

2/17/10

10/1/10

Housing Assistance Type Short-term Rent, Mortgage, and Utility Assistance (STRMU) Transitional/short-t erm facilities developed with capital funds, and placed in service during the op Transitional/short-t erm facilities that receive operating subsidies Permanent housing facilities developed with capital funds, and placed in service during the operatin lities that receive operating Permanent housing facisubsidies/lease d units Tenant-Based Rental Assistance (TBRA) Short-term Rent, Mortgage, and Utility Assistance (STRMU) Transitional/short-t erm facilities developed with capital funds, and placed in service during the op

Obtained Employment

Yes

No

No

No

No

No

No

No

Part 4: Section 3 Detail - Questions 1A to 1D

maintaining or establishing stable on-going housing Has contact with case manager/benefits counselor contact with a primary health care provider Has accessed and can maintain medical insurance/assistance Successfully accessed or maintained qualification for sources of income.

Client ID

Entry Date

Exit Date

143530

12/1/09

10/1/10

143532

9/1/10

10/1/10

144858

9/30/10

144860

2/1/10

Housing Assistance Type Transitional/short-t erm facilities that receive operating subsidies lities that receive operating Permanent housing facisubsidies/lease d units Short-term Rent, Mortgage, and Utility Assistance (STRMU) Short-term Rent, Mortgage, and Utility Assistance (STRMU)

Obtained Employment

No

No

No

No

Part 4: Section 3. Access to Care and Support: Assessment of Client Outcomes on Access to Care and Support

1a. Total Number of Households

1. For Project Sponsors/Subrecipients that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded services:

a. Housing Subsidy Assistance (duplicated)- TBRA, STRMU, PHP, Facility-Based Housing, and Master Leasing b. Case Management c. Adjustment for duplication (subtraction) d. Total Households Served by Project Sponsors/Subrecipients with HOPWA Housing Subsidy Assistance (Sum of Rows a. & b. minus Row c.) 2. For Project Sponsors/Subrecipients did NOT provide HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded services: a. Case Management b. Total Households Served by Project Sponsors/Subrecipients without Housing Subsidy Assistance

21 1 0 6

1 6

Part 4: Section 3 Access to Care and Support: Assessment of Client Outcomes on Access to Care and Support 1b. Status of Households Accessing Care and Support
[1] For project sponsors/subrecipients that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following:
4

Categories of Services Accessed

[2] For project sponsors/subrecipient s that did NOT provide housing subsidy assistance, identify the households who demonstrated the following:
0

Outcome Indicator

1. Has a housing plan for maintaining or establishing stable on-going housing 2. Has contact with case manager/benefits counselor consistent with the schedule specified in clients individual service plan. 3. Had contact with a primary health care provider consistent with the schedule specified in clients individual service plan. 4. Has accessed and can maintain medical insurance/assistance. 5. Successfully accessed or maintained qualification for sources of income.

Support for Stable Housing Access to Support Access to Health Care Access to Health Care Sources of Income

2 2 4 3

0 0 0 0

1C. Number of Households Obtaining Employment [2] For project sponsors/subrecipient that did NOT provide HOPWA housing subsidy assistance, identify the households who demonstrated the following:

Categories of Services Accessed

[1 For project sponsors/subrecipients that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following:

Total number of households that obtained an income-producing job Client ID

0 Housing Assistance Type Earned Income Start Date

Part 4: Section 3 Detail - Questions 2A to 2D

maintaining or establishing stable on-going housing Has contact with case manager/benefits counselor Successfully accessed or maintained qualification for sources of income.

Client ID

Entry Date

Exit Date

143504

10/15/09

143531

10/31/10

143886

3/1/10

143891

2/1/10

143895

4/1/10

144859

1/1/10

Housing Assistance Type Receiving NO HOPWA housing assistance Receiving NO HOPWA housing assistance Receiving NO HOPWA housing assistance Receiving NO HOPWA housing assistance Receiving NO HOPWA housing assistance Receiving NO HOPWA housing assistance

contact with a primary health care provider

Has accessed and can maintain medical insurance/assistance

Obtained Employment

Yes

No

No

No

No

No

Part 5: Summary of Each Project Sponsor(s)/Subrecipient(s) Information B. Rental Assistance, Short-Term Rent, Mortgage and Utility Assistance Programs, and Permanent Housing Placement Assistance
1. Rental Assistance (RA) Enter the total number of households served in Column [1] and the amount of HOPWA funds expended Column [2] by the project sponsor/subrecipient on RA. [2] Output: Total HOPWA Funds [1] Output: Number of Expended during Operating Year HOPWA Housing Subsidy Assistance Category: RA Households Served by Project Sponsor/Subrecipient a. Tenant-based rental assistance (TBRA) Other Rental Assistance (RA) Programs (if approved in grant agreement) Direct program delivery costs (e.g., program staff time) TOTAL Rental Housing Assistance (For Column [1] sum of Row a. & Row b., for Column [2] sum of rows a. c.) 4 Not Provided by HMIS

b. c.

Not Provided by HMIS Not Provided by HMIS

d.

Not Provided by HMIS

2. Short-Term Rent, Mortgage and Utility Assistance (STRMU) [1] Output: Number of Households Served 5 [2] Output: Total HOPWA Funds Expended on STRMU during Operating Year Not Provided by HMIS

Housing Subsidy Assistance Categories (STRMU) a. Total Short-term mortgage, rent and/or utility (STRMU) assistance Of the total STRMU reported on Row a, total who received assistance with mortgage costs ONLY. Of the total STRMU reported on Row a, total who received assistance with mortgage and utility costs. Of the total STRMU reported on Row a, total who received assistance with rental costs ONLY. Of the total STRMU reported on Row a, total who received assistance with rental and utility costs. Of the total STRMU reported on Row a, total who received assistance with utility costs ONLY. Direct program delivery costs (e.g., program operations staff)

b.

Not Provided by HMIS

c.

Not Provided by HMIS

d.

Not Provided by HMIS

e.

Not Provided by HMIS

f. g.

0 Not Provided by HMIS

Not Provided by HMIS Not Provided by HMIS

3. Permanent Housing Placement Services [2] Output: Total HOPWA Funds Expended on STRMU during Operating Year Not Provided by HMIS

[1] Output: Number of ing Subsidy Assistance Category: Permanent Housing Placement Assistance Served Households a. Permanent Housing Placement Services Direct program delivery costs (e.g., program staff time) TOTAL Permanent Housing Placement Services (Sum of Rows a. and b.) 0

b. c.

Not Provided by HMIS 0 Not Provided by HMIS

Part 5: Summary of Project Sponsor Information D. Supportive Services

2. Listing of Suportive Services provided by Project Sponsor Agency
Supportive Services 1. 2. 3. 4. 5. 6. Adult day care and personal assistance Alcohol and drug abuse services Case management/client advocacy/ access to benefits & services Child care and other child services Education Employment assistance and training Health/medical/intensive care services, if approved Note: Client records must conform with 24 CFR 574.310 Legal services Life skills management (outside of case management) Meals/nutritional services Mental health services Outreach AIRS Code PH-1600.0500 LX-0400.2500 PH-1000 PH-1600 H ND Number of Households Receiving HOPWA Assistance 2 0 2 1 2 1 Amount of HOPWA Funds Expended Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS

7. 8. 9. 10 11. 12. 13. 14.

L FT PH-6200.4600 BD-5000 R TJ-6500.6300

0 0 1 0 1 1 1 3

Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS Not Provided by HMIS

15. 16.

17

Transportation BT Other Activity (if approved in grant agreement). See Table 2.1 below for total & breakdown Sub-Total Households receiving Supportive Services (Sum of Rows 1-14) Adjustment for Duplication (subtract) TOTAL Households receiving Supportive Services (unduplicated)

15 2 Not Provided by HMIS

Housing Placement Assistance

18. 19. 18. Housing Information Services TOTAL Housing Information Services Permanent Housing Placement Services Adjustment for duplication (subtract) TOTAL Housing Placement Assistance (unduplicated, sum of items 17 + 18)

13 # Households Receiving HOPWA Categories Number of Households Receiving HOPWA Assistance Assistance 0 0 0 0

Not Provided by HMIS

Not Provided by HMIS

Not Provided by HMIS Not Provided by HMIS

Not Provided by HMIS

Table 2.1: OTHER Supportive Services Total: Service Name Clowning Clubs Real Estate Auctions Synchronized Swimming AIRS Code PS-8200.1350-150 BH-6820 PL-7000.8830 3 Number of Households Receiving HOPWA Assistance 1 1 1

Part 5: Section 2 - Detail: By Household Group ID

Client ID 143509 143512 143513 143531

Single Individuals: No Group ID

Group ID Household ID Provider of Service CT HMIS Reporting Demo HOPWA(942) CT HMIS Reporting Demo HOPWA(942) CT HMIS Reporting Demo HOPWA(942) CT HMIS Reporting Demo HOPWA(942) AIRS Code PS-8200.1 350-150 PL-7000.8 830 BH-6820 PH-1000 Description Clowning Clubs Synchronized Swimming Real Estate Auctions Case/Care Management Start Date 1/15/10 2/15/10 4/15/10 11/1/10 11/1/10 End Date

Part 6: Worksheet - Determining HOPWA Outcomes and Connections with HMIS

1. This Chart is designed to help you assess program results based on the information reported in Part 4.
A Permanent Housing Assistance Tenant-based Rental Assistance (TBRA) Permanent Facility-Based Housing Assistance/Units Transitional/Short-term Facility-Based Housing Assistance/Units Total Permanent HOPWA Housing Assistance Reduced Risk of Homelessness: Short-Term Assistance Short-term Rent, Mortgage, and Utility Assistance (STRMU) Total HOPWA Housing Assistance (# remaining in program plus 3+4+5+6=#) 4 2 B Temporary Housing (2) 0 0 C Unstable Arrangements (1+7+8=#) 0 0 D Life Event (9) 0 0

3 9 Stable/Permanent Housing

0 0 Temporarily Stable, with Reduced Risk of Homelessness

1 1

0 0

Unstable Arrangements

Life Event

3 12

1 1

0 1

1 1

Utilization for Period

Note: To determine the number of Beds or Units for your program, contact CARC. Single individuals are counted in beds unless the "Count this Client as a Household of 1?" question is changed to "Yes" at program entry. They are then counted as in Units ONLY.

Bed Utilization Over Report Period

Nights from Start to End of Period x 639 = Bed Nights Used (BNU) 5,844

# of Beds (Start of Report Period) 0

Bed Nights Available (BNA) 0

# of Individuals in Beds 17

Bed Night Utilization Rate (BNU) * 100 / BNA N/A

Unit Utilization Over Report Period

Nights from Start to End of Period x 639 = # of Households and Households of 1 in Units 10 Unit Nights Used (UNU) 5,812

# of Units (Start of Report Period) 0

Unit Nights Available (UNA) 0

Unit Night Utilization Rate (UNU) * 100 / UNA N/A

Client Info Client ID 132472 138819 138820 138821 138822 138824 143453 143454 143466 143503 143504 143506 143508 143509 143512 143513 143515 143519 143525 143530 143531 143532 143886 143887 143891 55 32 49 24 27 51 48 23 33 30 40 39 27 21 24 48 20 64 24 22 29 Age at Entry 49

Household Info HoH No No Yes No No No No No No No No No No No No No No No No No No No Yes No Yes 126761 126761 126764 HH of 1 HH of 1 HH of 1 HH of 1 HH of 1 HH of 1 122581 122581 Group ID

Program Stay Entry Date 11/4/09 12/21/10 12/21/09 12/21/09 4/21/09 4/21/09 2/17/10 11/2/09 3/1/10 6/15/08 10/15/09 11/3/09 12/1/09 1/1/10 2/1/10 4/1/10 5/1/10 7/1/10 2/17/10 12/1/09 10/31/10 9/1/10 3/1/10 3/1/10 2/1/10 Exit Date 1/3/11 12/21/10 12/1/10 12/1/10 Ongoing 10/1/10 Ongoing Ongoing Ongoing Ongoing Ongoing 10/1/10 Ongoing Ongoing Ongoing Ongoing Ongoing 10/30/10 10/1/10 10/1/10 Ongoing 10/1/10 Ongoing Ongoing Ongoing

Program LOS (Days) 969 557 922 922 1,166 1,166 864 971 852 1,476 989 970 942 911 880 821 791 730 864 942 608 668 852 852 880

Report Stay Entry 10/1/10 12/21/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/31/10 10/1/10 10/1/10 10/1/10 10/1/10 Exit 1/3/11 12/21/10 12/1/10 12/1/10 6/30/12 10/1/10 6/30/12 6/30/12 6/30/12 6/30/12 6/30/12 10/1/10 6/30/12 6/30/12 6/30/12 6/30/12 6/30/12 10/30/10 10/1/10 10/1/10 6/30/12 10/1/10 6/30/12 6/30/12 6/30/12

Report LOS (Days) 94 0 61 61 639 0 639 639 639 639 639 0 639 639 639 639 639 29 0 0 609 0 639 639 639

Utilization for Period

143892 143893 143895 143896 144858 144859 144860 28 8 5 29 25 21 28 No No Yes No No No No 126764 126764 126769 126769 2/1/10 2/1/10 4/1/10 4/1/10 9/30/10 1/1/10 2/1/10 Ongoing Ongoing Ongoing Ongoing Ongoing Ongoing Ongoing 880 880 821 821 639 911 880 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 10/1/10 6/30/12 6/30/12 6/30/12 6/30/12 6/30/12 6/30/12 6/30/12 639 639 639 639 639 639 639