SFY 2009 EFS and SH Service Reporting

SFY 2009 EFS and SH Service Reporting Illinois Department of Human Services(IDHS) XYZ Project - EFS Choose Quarter Contract: 999999999999 Q2 - Oct. 1 - Dec. 31 Load Quarter

Quarter 2 - step 1 of 22 next Adults Children Sing. male 0 Sing. female 0 Entering: 0 0 Couple no child 0 Couple w/child 0 Exiting: 0 0 Male w/child 0 Female w/child 0

Participants Served during the quarter. Adults * Children Under 18 Total a. Number entering program during the quarter: 0 0 0 b. Number leaving program during the quarter: 0 0 0

* Add Emanicipated or Unaccompanied Youth to the 'Adults' column. Emanicipated or Unaccompanied Youth are defined as: - emancipated minors, unaccompanied youth, married youth and / or a youth with child. Report an UNDUPLICATED count of households, by type, entering the program during the report quarter. 0 0 0 Single Male: Couple No Child: Male W/Child: 0 0 0 Single Female: Couple W/Child: Female W/Child: Total Unduplicated Households: Prior Living situation: How many participants slept in the following places in the week prior to entering the project? For each participant, choose only one place. Prior Living Situation Adults Children Under Age 18

Carry-over from Quarter 4 0 0

Non-housing (street, park, car, bus station, etc.) 0 0

Emergency Shelter 0 0

Transitional Housing for homeless persons 0 0

Psychiatric facility 0 0

Substance abuse treatment facility 0 0

Hospital 0 0

Jail / Prison 0 0

Domestic violence situation 0 0

Living with relatives / friends 0 0

Rental housing / Eviction 0 0

Disaster / Fire 0 0

Condemned housing 0 0

Other - specify 0 0

Other - specify 0 0 Other - specify 0 0

Totals 0 0 Report the number of participants entering the program that used other shelters during the prior year. Children Under Number of Shelters Adults Age 18

None 0 0

5 or more 0 0

Totals 0 0 Age and Gender of the total who entered the project during the quarter, how many people are in the following age and gender catagories? Age Male Female

62 and over 0 0

51 - 61 0 0

31 - 50 0 0

Total 18 - 30 0 0 Adults Emancipated Minor or Unaccompanied Youth 0 0 0 *

13 - 17 0 0

6 - 12 0 0

Total 1 - 5 0 0 Children

under 1 0 0 0 Click to add reunited family members or newborns to a household for the quarter. Age and Gender of newborns and/or other family members reunited with a participant who entered the project in a previous quarter and is currently in the project? Age Male Female

62 and over 0 0

51 - 61 0 0

31 - 50 0 0

Total 18 - 30 0 0 Adults Emancipated Minor or 0 0 0 Unaccompanied Youth *

13 - 17 0 0

6 - 12 0 0

Total 1 - 5 0 0 Children

under 1 0 0 0

* Emanicipated or Unaccompanied Youth are defined as: - emancipated minors, unaccompanied youth, married youth and / or a youth with child. Ethnicity: How many participants are in the following ethnic categories? Children under Age Ethnicity Adults 18

Hispanic or Latino 0 0

Non-Hispanic and Non-Latino 0 0

Totals 0 0 Race: How many participants are in the following racial categories? Race Adults Children under Age 18 American Indian / Alaskan Native 0 0

Asian 0 0

Black / African American 0 0

Native Hawaiian / Other Pacific Islander 0 0

White 0 0

American Indian / Alaskan Native & White 0 0

Asian & White 0 0

Black / African American & White 0 0

American Indian / Alaskan Native & Black / African American 0 0

Other * 0 0 Totals 0 0 * This category is for all participants who do not declare themselves in any of the other categories. Special Needs / Conditions: For new participants report a DUPLICATED count of the number of indivinduals with the following special needs/conditions. This may not apply to all participants, ie. neither adults nor children may have special needs. Special Need / Conditions Adults Children under Age 18 Substance Abuse (SA) 0 0

Alcohol Abuse (AA) 0 0

Mental Illness (MI) 0 0

Developmental Disability (DD) 0 0

Physical Disability (PD) 0 0

HIV and / or AIDS (HIV) 0 0

Chronic Medical Health Problem 0 0

Domestic Violence 0 0

Unaccompanied Youth 0 0

Pregnant / Paranting Teen 0 0

Ex-Offenders 0 0 Other - specify 0 0

Other - specify 0 0

Other - specify 0 0 Totals 0 0 How many of the participants are disabled? This may not apply to all participants, ie. zero is an acceptable entry if no participants have a 0 disabling condition. Disabling condition - A disabling condition is defined as:

1. A disability as defined in Section 223 of the Social Security Act; 2. a physical, mental, or emotional impairment which is: o expected to be of long- continued and indefinite duration, o substantially impedes an individual's ability to live independently, and o of such a nature that such ability could be improved by more suitable hoursing conditions; 3. a developmental disibility as defined in section 102 of the Developmental Disabilities Assistance and bill of Rights Act; 4. the disease of acquired immunodeficiency syndrome or any conditions arising from the etiological agency for acquired immunodeficiency syndrome; or

5. a diagnosable substance abuse disorder. How many of the participants were veterans? This may not apply to 0 all participants, ie. zero is an acceptable entry. A veteran is anyone who has ever been on active military status. Participant Income: For participants entering the program during the report quarter, enter the number of participants monthly cash income level. For participants leaving the program during the report quarter, enter the number of participants with cash income at each income level. AT ENTRY | AT EXIT Gross Monthly Income Adults Children under 18 | Adults Children under 18 No Income 0 0 | 0 0

$1 to 150 0 0 | 0 0

$151 to 250 0 0 | 0 0

$251 to 500 0 0 | 0 0

$501 to 1000 0 0 | 0 0

$1001 to 1500 0 0 | 0 0

$1501 to 2000 0 0 | 0 0

$2001 + 0 0 | 0 0 Totals 0 0 | 0 0 Report the number of participants entering during the quarter that received cash income from each applicable category. For those leaving during the quarter, report the number with cash income from each applicable category. Adults and children reported as 'No Income' in step 11 can NOT be recorded on this step. AT ENTRY | AT EXIT Source of Income Adults Children under 18 | Adults Children under 18 AABD 0 0 | 0 0

Alimony / Spousal Support 0 0 | 0 0

Child Support (or DCFS Grant) 0 0 | 0 0

Employment and Training 0 0 | 0 0

Employment Income 0 0 | 0 0

Pension / Retirement 0 0 | 0 0

Private Disability Insurance 0 0 | 0 0 Social Security 0 0 | 0 0

SSDI 0 0 | 0 0

SSI 0 0 | 0 0

Targeted Work Initiative 0 0 | 0 0

Temp. Asst. Needy Families (TANF) 0 0 | 0 0

Transitional / GA / Earnfare 0 0 | 0 0

Unemployment Benefits 0 0 | 0 0

Veterans Benefits 0 0 | 0 0

Work First / Work Pays 0 0 | 0 0

Worker's Compensation 0 0 | 0 0 Totals 0 0 | 0 0 Participation Benefits: Report the number of Participants entering and the number leaving during the quarter that received non-cash benefits from each category. It is possible for a participant to receive benefits from several programs. AT ENTRY | AT EXIT Source of Benefits Adults Children under 18 | Adults Children under 18 All Kids 0 0 | 0 0

Child care Assistance 0 0 | 0 0

Emergency Food Assisstance 0 0 | 0 0

LIHEAP 0 0 | 0 0

Teen Parent Program 0 0 | 0 0

WIC 0 0 | 0 0

Medical Card 0 0 | 0 0

Other - specify 0 0 | 0 0

Other - specify 0 0 | 0 0 Totals 0 0 | 0 0 Required Service: Report an unduplicated count of each household's food stamp status. Currently Enrolled (prior to entering the Agency Enrolled (after entrance to Entitlement Program Ineligible program) program) Food Stamps 0 0 0 Totals 0 Shelter / Meals: Report the total nights of shelter and meals provided during this report quarter. Shelter Nights Overnight Voucher Transitional Supportive Housing Male Adults 0 0 0 0

Male Children 0 0 0 0

Female Adults 0 0 0 0

Female Children 0 0 0 0 Shelter Nights Totals 0 0 0 0 Meals Served / purchased / vouchered for all 0 0 0 0 participants Report a DUPLICATED count of adults and children receiving services during the quarter. Adult services are required to be reported here, children services are not required. Supportive Services Adults Children Advocacy 0 0

Case Management 0 0 Counseling - The total of each of the three counseling categories must be at least as great as the number of individuals in the program for the quarter. - Financial 0 0 - Life Skills 0 0 - All Other 0 0

Alcohol Abuse Services 0 0

Child Care 0 0

Children's Services 0 0

Education 0 0

Employment Services 0 0

English as Second Language 0 0

Follow-up Services 0 0

Health / Dental Service 0 0

HIV / AIDS Related Services 0 0

Housing Location / Inspection 0 0

Mental Health Services 0 0

Legal Service Referrals 0 0

Outreach 0 0

Substance Abuse Services 0 0

Transportation 0 0

Other - specify 0 0

Other - specify 0 0 Totals 0 0 Of those participants who left during the quarter, how many were in the project for the following lengths of time? Time Period Adults Children Under Age 18 Less than 1 month 0 0

1 to 2 months 0 0

3 - 6 months 0 0

7 - 12 months 0 0

13 - 24 months 0 0

25 months - 3 years 0 0

4 - 5 years 0 0

6 - 7 years 0 0

8 - 10 years 0 0 10 years and up 0 0 Totals 0 0 For participants who left the program during the quarter and are not expected to return, complete the chart below by including only the primary reason for departure. Report an UNDUPLICATED count. Reason for Departure Adults Children Under Age 18 Left for housing opportunity before 0 0 completing program Completed program 0 0

Non-payment of rent / occupancy charge 0 0

Non-compliance with project 0 0

Criminal activity / destruction of property / 0 0 violence Reached maximum time allowed in project 0 0

Needs could not be met by project 0 0

Disagreement with rules / persons 0 0

Death 0 0

Voucher funds exhausted 0 0

Voluntary Departure 0 0

Unknown / disappeared 0 0

Other - specify 0 0

Other - specify 0 0 Totals 0 0 For participants who left the program during the quarter and are not expected to return, how many left for the following destination? Type Destination Adults Children Under Age 18

Rental house or 0 0 apartment (no subsidy)

Public Housing 0 0

Section 8 0 0

Shelter Plus Care 0 0 PERMANENT HOME subsidized house 0 0 or apartment

Other subsidized house 0 0 or apartment

Homeownership 0 0

Moved in with family or 0 0 friends

Transitional housing for 0 0 homeless persons TRANSITIONAL Moved in with family or 0 0 friends

INSTITUTIONAL Psychiatric hospital 0 0

Inpatient alcohol or 0 0 other drug treatment facility Jail / prison 0 0

EMERGENCY Emergency Shelter 0 0 SHELTER

Other supportive 0 0 housing Places not meant for OTHER human habitation (e.g. 0 0 street) Other - specify 0 0

UNKNOWN Unknown 0 0

Totals 0 0 Report a DUPLICATED count for each denial of service to participants. Enter zero if no denials were given. Reason For Turnaway Adults Children Under Age 18 No Vacancy 0 0

No Voucher Funds 0 0

Inappropriate for shelter 0 0

Refused to accept rules 0 0

Found other housing 0 0 Totals 0 0 How many of the participants reported as turned away in STEP 20 were referred to 0 another shelter? Enter zero if no participants were turned away in STEP 20. Please identify the number of participants who CANNOT speak or read English well. Identify their native or primary language by the following categories. Category Number of Adults Number of Children

Albanian 0 0

Arabic 0 0

Bosnian 0 0

Bulgarian 0 0

Chinese 0 0

French 0 0

Gujarati 0 0

Hindi 0 0

Khmer 0 0

Korean 0 0

Lithuanian 0 0

Mandingo 0 0

Polish 0 0

Romanian 0 0

Russian 0 0

Spanish 0 0 Ukranian 0 0

Urdu 0 0

Uzbek 0 0

Vietnamese 0 0

Other - Asian 0 0

Other - African 0 0

Other - Central and South American 0 0

Other - European 0 0

Other - India 0 0

Other - specify 0 0

Totals 0 0 next step

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