Transportation assistance to clients to attend mainstream benefit appointments, employment training, or jobs? Yes No Regular follow-ups with participants to ensure mainstream benefits are received and renewed? Yes No Will project participants have access to SSI/SSDI technical assistance provided by the applicant, a subrecipient, or partner agency? Yes No Indicate the last SOAR training date for the staff person providing the technical assistance: _____________ 12. Supportive Services Type and Frequency: A. For all supportive services available to participants, indicate who will provide, how they will be accessed and how often they will be provided regardless of the resources that will be used to pay for the services. For Provider, indicate: “Applicant” if the applicant will provide the service directly; “Subrecipient” if a subrecipient will provide the service directly; “Partner” if an organization that is not a subrecipient of project but with whom a formal agreement or memorandum of understanding (MOU) has been signed will provide the service directly; or, “Non-Partner” to if a specific organization with whom no formal agreement has been established regularly provides the service to clients. Supportive Services Provider Frequency – select one per service type Weekly Monthly N/A Assessment of Service Needs Assistance with Moving Costs Case Management Child Care Education Services Employment Assistance/Job Training Food Housing Search/ Counseling Services Legal Services Life Skills Mental Health Services Outpatient Health Services Outreach Services Substance Abuse Treatment Services Transportation Utility Deposits
B. How accessible are community amenities (e.g. medical facilities, grocery store, recreation facilities, schools, etc) to the proposed project? Yes, very accessible Somewhat accessible Not accessible 13. Population Characteristics Population Characteristics Persons in HH’s with At Least One Adult and One Child Adult Persons in Households without Children Persons in Households with Only Children Total Disabled Adults over age 24 Non-disabled Adults over age 24 Disabled Adults ages Non-disabled Adults ages 18-24 Accompanied Disabled Children under age 18 Accompanied Children under age 18 Unaccompanied Disabled Children under age 18 Unaccompanied Children under 18 Totals from Above: Total Number of Adults over age 24 Number of Adults ages 18-24 Number of Children under 18 Total Persons 14. Subpopulations – For PSH, each person must be listed as chronically homeless and at least one adult in each household must be listed as disabled. DV is not considered a disability by HUD. Households with At Least One Adult and One Child Chron. Chron. Chronic Persons Severely Dom. Phys. Dvlpmt Not Non- Non-
Homlss Non- Vets Homlss Vets Subs. with HIV/ AIDS Mentally Ill Disab Disab Other-wise Represented Disabled Adults over age 24 Non-disabled Adults over age 24 Disabled Adults ages 18-24 Non-disabled Adults ages 18-24 Disabled Children under age 18 Non-disabled Children under age 18 Total Persons Households without Children Chron. Homlss Non- Vets Chron. Homlss Vets Chronic Subs. Abuse Persons with HIV/ AIDS Severely Mentally Ill Victims of Dom. Viol. Phys. Dvlpmt Disab Not Other-wise Represented Disabled Adults over age 24 Non-disabled Adults over age 24 Disabled Adults ages