Form Hud-92456 - Semi-Annual Performance Report Form - U.s. Department Of Housing And Urban Development

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Semi-Annual Performance Report
U.S. Department of Housing
OMB Approval No. 2502-0447
(exp. 06/30/2003)
and Urban Development
Multifamily Housing
Office of Housing
Service Coordinator Program
Federal Housing Commissioner
Public reporting burden for this collection of information is estimated to average X hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency
may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
Instructions: See pages 3 and 4 for detailed instructions.
1. Contact Person (name and phone number including area code) 2. Source of funds for Service Coordinator (check one)
Grant/Contract - provide number (e.g., OK56CS94032)______________________
Residual Receipts
Excess Income
E-Mail Address:
Section 8 operating funds (project-based)
3. Project(s) served by the Service Coordinator(s) (List additional developments on a separate page)
Project Name
Project/FHA Number
Number of Units
4. Number of hours per week worked by the Service Coordinator
5. Resident Statistics
a. Total number of residents in all projects served
b. Estimated Age of residents
percent aged 18 to 61 (i.e., non-elderly people with disabilities)
percent aged 62 to 80
percent aged 81 to 95
percent over age 96
c. Estimated number of frail elderly residents (deficient in 3 or more Activities of Daily Living (ADLs))
d. Estimated number of at-risk elderly residents (deficient in 1 or 2 ADLs)
e. Total number of residents who utilized the SC during this reporting period
f. Total number of newly assigned residents assisted during this reporting period
6. Type of Service Coordination Performed
For each service, provide the number of residents who received that service. Identify only those residents who went through the SC to obtain these services.
Type of Service
Number of Residents
Type of Service
Number of Residents
Home Management
Lease Education
Case Management
Mental Health Services
Conflict Resolution
Monitoring Services
Crisis Intervention/Support Counseling
Substance Abuse
Transfer to Alternative Housing or Hospital
Family Support
Health Care/Services
Other (specify)
7. Administrative Tasks
List the approximate percentage of time per month the SC performs these administrative tasks.
Documentation of resident files
Paperwork not related to a resident
Contact with outside service providers
Meetings with management staff
Name of person preparing this report
Date (mm/dd/yyyy)
Page 1 of 4
form HUD-92456 (08/2000)


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