Intro

The form below asks for information about your agency's participation and activities in the Balance of State Continuum of Care. This information is required to be included on the BoS's funding application to HUD. Please answer all of the questions to the best of your ability. If a question doesn't apply to you, please choose "None" or "Not applicable."

Thank you!

Organization/Agency

Counties Served by Your Agency

Contact Person

Job Title

Mailing Address

City

State

Zip Code

Phone Number

Email Address (Enter twice to verify)

Agency's Website

Organization's Type of Membership

Public Sector

Private Sector

Individual Person

Role in Balance of State CoC (Select all that apply)

Participate in Regional Committee (local CoC) or any other Balance of State committee (Transitional Housing; Permanent Housing; Families; Scorecard; Ranking)

Participate in Balance of State Steering Committee meetings (primary decision-making group)

Authoring Agency for Consolidated Plan

Attended Consolidated Plan planning meetings during past 12 months

Attended Consolidated Plan focus groups/public forums during past 12 months

Attended 10-Year Plan planning meetings during past 12 months

Lead agency for 10-Year Plan

None of the above

Subpopulations represented or served by the organization (Select no more than 2)

Seriously Mentally Ill

Substance Abuse

Veterans

HIV/AIDS

Domestic Violence

Youth

None of the above

Do your agency's case managers systematically assist clients in completing applications for mainstream benefits (such as Medicaid, SSI/SSDI, Work First/TANF, SNAP/Food Stamps, etc.)?

If you are an agency that provides mainstream benefits (such as DSS), do you use a single application for four or more mainstream programs?

If yes, what are the mainstream programs included on this application?

Does your program use HMIS as a way to screen for mainstream benefit eligibility?

If "Yes", indicate which mainstream benefit program eligibility screenings are completed using HMIS.

Medicaid

SNAP (Food Stamps)

TANF/Work First

SSI/SSDI

Other

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

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

Balance of State Participants

Intro