Form Hud 92456 – Fill Out and Use This PDF

Public reporting burden for this collection of information is estimated to average 4 hours per response, including the time f or 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 control number.

Instructions: See pages 3 - 5 for detailed instructions.

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5. People S erved

a.R esident Age R anges

Frail Elders

At Risk Elders

Non-elders

All others

Total

c.Neighbors S erved

Number of low­income elderly or people with disabilites who live in the neighborhood and whom you assisted during the reporting the period.

d. First Timers

Number of individuals whom you assisted for the first time during this reporting period.

All other project residents

6. Type of Service Coordination Performed (click on title for Glossary of Service Types)

(For each service, provide the number of project and neighborhood residents whom you assisted and number of contacts you made.

Count the individuals only once, but provide the total number of contacts for each individual.

7. Aging in Place Statistics for Residents Who Moved Out of the Project During the R eporting Period.

Number of residents who died

Number of residents who moved to a higher level of care

Number of residents who moved in with family

Number of residents evicted

Other

Total number of move-outs

8. Time Allocation of Monthly Tasks (List approximate % of time per month you performed these tasks. S um of all should equal 100%)

9. Professional Training Duration (hours or days )

List the training programs you attended during this reporting period. Provide the name of the training provider and program, its location, number of hours, and the number of continuing education hours earned.

10. Educational / Preventative Health Programs

List the programs you implemented for project and/or neighborhood residents during this reporting period.

11. Fundraising

Fundraising activities are optional, but if you have engaged in any activities during the reporting period, please list them.

12. Community Engagement

List meetings or visits with community partners and attendance at or planning of community events that encourage interaction between the

community and project residents.

13. Resident Problems / Issues

Provide anecdotes (no more than two paragraphs each) describing two resident issues with which you were involved during this reporting period.

14. Additional Information

Provide any other information relevant to the administration and performance of the Service Coordinator Program. Provide any recommended "Best Practices" you have found to be effective in providing service coordination and promoting independent living for residents.

HUD's definition of ADLs includes eating, dressing, bathing, grooming, and transferring, as further described below:

(1)Eating--may need assistance with cooking, preparing, or serving food, but must be able to feed self;

(2)Bathing--may need assistance in getting in and out of the shower or tub, but must be able to wash self;

(3)Grooming--may need assistance in washing hair, but must be able to take care of personal appearance;

(4)Dressing--must be able to dress self, but may need occasional assistance;

(5)Transferring---actions such as going from a seated to standing position, getting in and out of bed, and using the toilet.

5c. Neighbors S erved. Provide the number of low-income elderly or people with disabilities who live in the neighborhood whom you assisted during the reporting period (if any). Working with neighborhood residents is optional. HUD is interested in knowing how many S ervice Coordinators serve the greater community and how many individuals are covered.

5d. First Timers. Provide the number of project residents and neighbors whom you assisted for the first time during the reporting period.

Make a distinction between those who moved in within the last six months ("New move-ins") and those who have lived in the project or neighborhood longer, but only started coming to you for assistance during this reporting period.

6.Type of S ervice Coordination Performed. For each of the listed services, provide the sum of project residents and neighbors (in the "Number of Individuals" column) who received that service during the reporting period. Provide the number of contacts

with all individuals related to those services. Choose only the category you feel most appropriately represents the service you coordinated.

Count individuals once but report each contact with that one person. For example, you assisted three project residents in obtaining transportation services during the reporting period. To do this you had to meet with one resident three times, another resident five times and the third resident three times. S o the number of individuals is three and the number of contacts is 11.

If you additionally helped one neighborhood resident obtain transportation services and if you met with that person three times during the reporting period, then the number of individuals will be 4 and the number of contacts will be 14. R efer to the Glossary of S ervice Types (HUD­92456­G) for explanations and examples of services.

7. Aging in Place S tatistics. Provide the number of project residents who left the project during the reporting period.

Residents counted in this section must have been residents of the project at the time of their departure. Do not count neighborhood residents. Provide the reason and number for each move-out. Add other reasons on the "Other" line if relevant.

HUD wants to know how the Service Coordinator program affects aging-in-place over time. Include the numbers from the last report as a comparison. You'll do this on each subsequent report. If you are a new S ervice Coordinator and don't have a previous report or access to previous data, indicate "No Data" in the revelant box.

8. Time Allocation of Monthly Tasks. List the approximate or average % of time per month you spent performing the listed tasks. Add others if appropriate. Sum of all should equal 100% of your average time each month.

*Contact with outside service providers. Includes any activity related to obtaining information about or advocating for affordable supportive services or assistance for residents. Such activity may include telephone conversations, face-to-face meetings, coalition or task force meetings, or working groups.

*Direct contact with project and neighborhood residents. This is the time you spend with your residents, for example in one­on­one meetings, informal conversation, while conducting needs screenings, or at educational program gatherings.

*Documentation of resident files. Includes any notes you make, forms completed, or other information entered in resident files.

*M eetings with property management staff. Includes meetings with site manager or administrator, supervisor, other property management staff, or any other related meeting.

*Paperwork not related to a resident. Includes any reports written for management staff, supervisors, or peers.

Also relevant is paperwork related to registering for training, arranging travel, or purchasing supplies or equipment.

*Researching available services. Includes time spent searching for program information on the Internet, by phone, reading literature, and meeting with knowledgeable professionals.

*O ther. If you perform other work on a monthly basis, please list function and percentage of time.

Please attach a Microsoft Word (or other text file) that contains brief responses to items 9-14. Your report is not

complete without this additional document and adequate responses to each item.

reporting period. Provide the following information for each program you attended:

*Name of the training program

*Name of sponsoring organization that planned and executed the training ( i.e. training provider)

*Location

*Duration ( hours or days)

*Number of training hours completed

* Training pursuant to guidance in HUD' s M anagement Agent Handbook4381 .5 REV ­ 2 CHG­ 2, Chapter 8.9. First time S ervice Coordinators must complete 36 hours in the first year of employment as a S ervice Coordinator, unless they have received recent revelant training. All other S ervice Coordinators must complete 12 hours of eligible training each year.

10.Educational and Preventative Health Pro grams. List the programs you developed and/or implemented for project and/or neighborhood residents during this reporting period. Provide the name or topic of each program only and give the approximate number of individuals who attended. Indicate whether events were one time only or ongoing programs.

Examples of such programs are talks on osteoporosis, nutrition, or accessibility issues for people with disabilities, “brown bag” medication meetings with pharmacists, or remembrance groups.

11. Fundraising. List optional fundraising activities, if any, completed during this reporting period. Provide the name

or brief description of each activity, the amount of funds raised, and the intended use of these funds. Please note that fundraising activities must relate to assisting the residents to age in place.

Examples of items that you might assist in fundraising include but are not limited to:

Another part-time Service Coordinator or aide position

Exercise equipment

Blood pressure machine for health clinic use

Ramp to make the project or immediate area more accessible

Purchase or lease of a van

Creation of computer Center and purchase of computer equipment

Examples of items that you should not directly engage in fundraising activities for include:

Holiday parties

Large screen TVs for community rooms

DVD players

Pianos and organs

Bingo sets

12. Community Engagement. List meetings with service providers and local area partners and attendance at or planning of local events that encourage interaction between the greater community and project residents.

Community engagement is defined as follows:

*Visits or meetings with new service providers and/or local vendors, churches, schools, etc.

*Attendance at community organization events that would make the greater community aware of your property and the needs of your residents.

*Planning events that encourage the greater community to visit and interact with project residents.

13. Resident Problems/Issues. Provide anecdotes (no more than two paragraphs each) describing two resident issues with which you were involved during the reporting period. Indicate whether or not the issue was resolved during the

reporting period. Describe positive and/or negative outcomes. The objective of this item is to give readers of the report

a description of your work and the types of issues dealt with on a daily basis. Unresolved situations will be viewed as

examples of difficult problems or circumstances and not as a negative reflection on your efforts. Please be candid in your account, in order to give the reader an accurate description of your work. Do not provide any personal identifiable

information.

14.Additional Information. Provide any other information relevant to the administration and performance of the Service Coordinator Program. Provide any recommended "Best Practices" you have found to be effective in providing service

coordination and promoting independent living for the residents. Examples of your "Best Practices" will be essential in helping others develop effective S ervice Coordinator programs and obtaining needed resources.