State of Tennessee

Transitional Housing Annual Report

Agency Name*

Reporting Person*

Edison Grant Number*

Phone*

(888) 888-8888

Email*

Reporting Period:

July 1 - June 30

Reporting Period:

July 1 - June 30

Section A. Outputs Clients Served:

People Served

A. Unduplicated # of TransHousing Clients

B. Total # of Occupancy Days/Bed Nights

Total

Women

Total A*

Total B*

Equals*

Children/Youth

Total A*

Total B*

Equals*

Men

Total A*

Total B*

Equals*

Other

Total A*

Total B*

Equals*

Total All:

#*

Section B. Outputs Housing Units by Type:

Public Housing

Number of Family Units*

Rental Property

Number of Family Units*

Other

Describe

Other

Describe

Demographics

Black/African American*

American or Native American*

Asian*

Hispanic or Latino*

Native Hawaiian/Other Pacific Islander*

White or European American*

Unknown or Other

Total All:

#*

Age and Gender

0-17

Female*

Male*

Other

18-24

Female*

Male*

Other

25-59

Female*

Male*

Other

60+

Female*

Male*

Other

Total All:

#*

Services Provided:

Case Management or Support Services:

Meaningful supportive contact with clients to provide assistance with planning, goal setting, assessing for advocacy needs, individual counseling, etc.

*Do not count brief phone calls or short check-ins.

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Child Care:

Child or Dependent care assistance (provided by agency)

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Children's Activities:

Example: 30 minute counseling session during a home visit or while working with a school on behalf of a child
Group supportive services include therapy support groups, art therapy group, groups classes, etc.

*Do not count brief encounters such as distribution of toiletries, food, toys, etc.

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Advocacy:

Victim advocacy/accompaniment to emergency medical care
Law enforcement interview advocacy/accompaniment
Individual advocacy (assist with applying for public benefits, return of personal property or effects)
Immigration visas, continued presence application, and other immigration relief

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Counseling/Support Groups:

Indicated in the Logic Model*

Yes No

# of Clients receiving Services

# of Client Contacts for this Services

Crisis Intervention:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Education:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Services

Employment Counseling:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Housing Advocacy:

Intervention with employer
Intervention with Creditor
Intervention with Landord
Intervention with Academic Institution

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Job Training:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Translation or Interpretation Services:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Transportation:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Other:

Indicated in the Logic Model*

Yes No

# of Clients Receiving Services

# of Client Contacts for this Service

Include a description below of what "Other" Service refers to above:

B. Required Client Outcomes

Outcome 1.

My immediate sense of safety and security has increased as a result of the services I received from this agency.

Strongly Agree*

Agree*

Neutral*

Disagree*

Strongly Disagree*

Total All:

#*

Outcome 2.

I have increased my income or access to community benefits as a result of my participation in this program.

Strongly Agree*

Agree*

Neutral*

Disagree*

Strongly Disagree*

Total All:

#*

Outcome 3.

As a result of my participation in this program I have located safe and affordable permanent housing.

Strongly Agree*

Agree*

Neutral*

Disagree*

Strongly Disagree*

Total All:

#*

Outcome 4.

I am satisfied with the Services I have received through this agency.

Strongly Agree*

Agree*

Neutral*

Disagree*

Strongly Disagree*

Total All:

#*