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2013 Balance of State Services Survey

Intro

This survey is for all service agencies in the Balance of State Continuum of Care. The questions below are required information for the Balance of State's 2013 CoC funding application.

Please answer all of the questions. Thank you for your participation!

Agency Name

City

Counties Served by Agency

Which BoS Regional Committee do you belong to?

Does your agency provide transportation assistance to clients to attend mainstream benefit appointments, employment training, or jobs?

Yes

No

Does your agency use a single application form for four or more mainstream benefit programs?

Yes

No

If yes, which programs are the application for?

Does your agency's staff systematically follow up to ensure mainstream benefits are received?

Yes

No

If yes, please describe how staff conducts follow-up.

Is your agency (alone or in partnership with another agency) working to enroll clients in Affordable Care Act programs (i.e. healthcare benefits exchange)?

Yes

No

If yes, please describe what actions your agency has taken.

Has your agency conducted any outreach to educate clients on the Affordable Care Act?

Yes

No

If yes, please describe the outreach/education activities.

Has your agency participated in any trainings about the Affordable Care Act?

Yes

No

If yes, please list the training(s).

NCCEH

PO Box 27692
Raleigh, NC 27611
Main Phone: 919.755.4393
Data Center: 919.410.6997
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