Wff Confidential Cover Sheet (Page 6 of 7) in pdf

WFF HNF Screening Tool

Respondent Study ID# __ __ __ - __ __ __

ETERMINATION OF PROGRAM ELIGIBILITY

: Please give me a few moments to review the information you’ve provided.

EAD

LIENT

: Complete the table below to determine whether the family is eligible.

NTERVIEWER

NSTRUCTION

PART A: MINIMUM ELIGIBILITY CRITERIA:

Currently literally homeless (Question 1)

At least 1 previous episode of literal homelessness (Question 3)

Head of Household is at least 18 years old (Question 5)

Has at least one child (Question 7) OR has a pregnant family member living with them

(Question 8)



Has at least two service needs, as indicated by the number of

marks in the scoring

column for Questions 10-21.

Income at or below 20% of the Area Median Income (AMI)

Family meets all minimum eligibility criteria listed above.

If NO, SKIP to wrap-up instructions for families that are not eligible on next page.

PART B: ADDITIONAL CONDITIONS:

More than 1 prior episode of literal homelessness in the last 3 years (Question 3) OR

3 or more moves in the last 12 months (Question 9)



More than 2 service needs/barriers identified (

marks for Questions 10-21) OR

elevated need on at least 1 service need/barriers [e.g., multiple episodes of mental

health (Question 13a) or substance abuse treatment (Question 15a)]

Potential for reunification of one or more children living elsewhere (Question 7)

Total the number of “yes” responses from Part B above:

_____

Families who meet all criteria listed in Part A are eligible for the program. If the number of

eligible families exceeds the number of available housing units, please prioritize those

families with greater needs as outlined below.

ELECT ONE

PRIORITY 3: Family meets all minimum eligibility criteria listed in Part A.

PRIORITY 2: Family meets minimum eligibility requirements in Part A PLUS one of the

additional conditions listed in Part B.

PRIORITY 1: Family meets minimum eligibility requirements in Part A PLUS two or more

of the additional conditions listed in Part B.

Page 6 of 7 – Prepared by Westat

Wff Confidential Cover Sheet Page 6