Housing Opportunities for Persons
With AIDS (HOPWA) Program
Reporting CoversheetName of Agency:
HIV Service Delivery Area:
Scope of Work: / Source of Funds:
Quarter/Reporting Period: / Year:
Prepared By: / Name:
If Initial Report
Check box→ / If Revised Report
Check box→ / Revision Date:
Electronically submit this report in Word (.doc) format to with a copy to . A confirmation email will be sent when the report is received. If a confirmation email is not received by the business day following your submission, please re-submit the report.
Reporting due dates:1st Quarter / Q1 Due / 2nd Quarter / Q2 Due / 3rd Quarter / Q3 Due / 4th Quarter / Q4 Due
HOPWA / Feb-Apr / May 15 / May-July / Aug 16 / Aug-Oct / Nov 15 / Feb-Jan* / Feb 15*
* Each report should have year-to-date information. The 4th Quarterly Report is a cumulative year-end report.
Project Sponsor Narrative Summary
Instructions: The following information should be specific to housing related activities.
1. Discuss any concerns and/or significant changes related to staffing at the Project Sponsor level (e.g. staff positions vacant longer than 90 days).
2. Describe any needs assessments or other activities to solicit community input that occurred during the quarter. Include public meetings/forums, advisory group meetings, ad hoc group meetings, web-based activities, and any major material distribution activities. (If appropriate, please attach copies of minutes and agendas to this report.)
3. Describe coordination activity that occurred during the quarter between the Project Sponsor and other service providers, including but not limited to: other housing programs, TB elimination programs, immunization programs, STD clinics, Federally Qualified Health Centers (FQHCs), health care delivery systems, and Ryan White Parts A, C, and D.
4. List and describe housing-related training provided to the Project Sponsor during the quarter.
5. Describe training/technical assistance (TA) needs expressed by the Project Sponsor staff. Describe the steps taken to secure training/TA. If further assistance is required in securing training/TA, please provide details.
Project Sponsor Information
Instructions: Report year-to-date information for each quarter; the 4th quarter report serves as the annual report. Please review responses to assure accuracy and completeness before submission. The colored cells indicate numbers that should match. The report period for the annual report is FEBRUARY 1 – JANUARY 31. Please note this report period is for the HOPWA Project year (12 months).
Part 1: Narrative and Performance Measures Assessment
A. STATUS OF HOPWA WAITING LIST
Provide the current number of HOPWA-eligible individuals on the waiting list for STRMU and TBRA.Number of eligible individuals on waiting list for STRMU
Number of eligible individuals on waiting list for TBRA
B. PERFORMANCE MEASURES EVALUATION
· Provide an overview of your program’s performance measure accomplishments for the project year as established in the program plan.
· Provide the number of NEW clients entering into each program activity during each quarter. Each client should only be listed once per program activity per project year, regardless of the number of times they received assistance. (For example, if an STRMU client received assistance in the 1st quarter, and then reapplied / received STRMU assistance in the 3rd quarter, they would only be counted once in the 1st quarter).
· All clients served within the 1st quarter should be counted regardless if they are continuing from the previous project year.
· Year to Date (YTD) clients should be the sum of quarters 1 through 4 and should be unduplicated per program activity.Performance Measure / Q1 / Q2 / Q3 / Q4 / YTD
Unduplicated / Yearly Goal / % of yearly Goal
a. / # of households to receive TBRA
b. / # of households to receive STRMU
c. / # of households to receive Supportive Services
d. / # of households to receive PHP
C. OUTCOMES ASSESSED
Briefly assess how HOPWA-assisted households were enabled to establish and/or better maintain a stable living environment in housing that is safe, decent, and sanitary, and reduce their risks of homelessness and improve their access to health-care and other supportive services. Provide success stories or examples illustrating how the HOPWA program prevented the clients’ risk of homelessness and/or helped them access medical care and supportive services. “None”, “N/A”, “No Progress” and/or cut and paste responses from previous reports are not acceptable.
D. BARRIERS AND RECOMMENDATIONS
Select one or more barriers encountered during this quarter from the following list:HOPWA/HUD Regulations
Rent Determination and Fair Market Rents
Credit History / Rental History
Criminal Justice History
Multiple Diagnosed Issues
Technical Assistance or Training Issues
Other (please specify):
Please describe the issues involved, actions taken in response to the barriers, and plans toward program improvement. For the 4th quarterly report, please summarize Barriers and Recommendations for the entire project year. Do not cut and paste from previous reports. This must be reviewed and updated each quarter. Emphasize issues that have workable solutions, rather than systemic issues such as lack of housing, etc.Barriers/challenges / Probable Causes / Attempted Solutions / TA Needs
E. TECHNICAL ASSISTANCE
Based on the program’s experience during this quarter, are there any areas in which technical advice or assistance is needed? If so, please describe. This must be reviewed and updated each quarter. Do not cut and paste from previous reports.
Part 2: Information on HOPWA Clients, Beneficiaries, and Households
F. HOPWA CLIENTS
Please indicate below the year-to-date unduplicated number of HOPWA clients who received HOPWA assistance during this project year. Rule of thumb: If the charts are not asking for TBRA and STRMU separately (as in this chart), then the count is an unduplicated count.Clients Served with HOPWA this project year / Total Number
Number of unduplicated HOPWA Clients served
G. SPECIAL NEEDS CLIENTS
Please indicate the total year-to-date number of HOPWA Clients who have the following special needs, if known. Clients may count in more than one category.Category / Veteran(s)
Total number of HOPWA clients
Category / Chronically Homeless
Total number of HOPWA clients
Revisions: Removed categories of Domestic Violence Survivors and Homeless
H. PRIOR LIVING SITUATION
· Row (a) Column 1: Enter the number of HOPWA clients that are continuing if they received HOPWA assistance in the prior project year and are also receiving HOPWA assistance in the current project year. Do not include beneficiaries.
· Under New HOPWA Clients - Please indicate the prior living situation year-to-date only for new HOPWA Clients who began receiving HOPWA housing assistance during this project year. DO NOT report the prior living situation of the HOPWA clients continuing from the prior project year in row (a). Only indicate the (one) category that best describes the clients’ most recent living situation.Category / 
Total # of HOPWA clients
a. / Continuing in the HOPWA program from the prior project year
New HOPWA Clients (began receiving HOPWA assistance this project year)
b. / Place not meant for human habitation
(such as a vehicle, abandoned building, bus/train/subway station/airport, or outside)
c. / Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher)
d. / Transitional housing for homeless persons
e. / Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod Rehab)
f. / Psychiatric hospital or other psychiatric facility
g. / Substance abuse treatment facility or detox center
h. / Hospital (non-psychiatric facility)
i. / Foster care home or foster care group home
j. / Jail, prison, or juvenile detention facility
k. / Rented room, apartment, or house
l. / Client-owned house
m. / Staying or living in someone else’s (family’s or friends’) room, apartment, or house
n. / Hotel or motel paid for without emergency shelter voucher
o. / Other
p. / Don’t Know or Refused
q. / TOTAL (add items a-p)
Please check: Row (q)  should equal the total number of HOPWA clients under Part 2, Section F
Removed requirement to report separately for TBRA and STRMU categories.
I. HOPWA BENEFICIARIES
Please report the total number year-to-date of HOPWA beneficiaries receiving HOPWA assistance. Beneficiaries are all HOPWA Clients and ALL associated members residing with the HOPWA client whose income was counted as part of the HOPWA client’s assistance eligibility criteria (roommates, paid caregivers, live-in aides are not beneficiaries).HOPWA Beneficiaries served with HOPWA assistance / 
TBRA / 
STRMU / 
Supportive Services / 
a. / Number of HOPWA Clients who received HOPWA assistance
b. / Number of other beneficiaries residing with the above HOPWA Clients in HOPWA-assisted housing
c. / Total number of beneficiaries served with housing assistance (a + b)
Removed requirement to report Row (b) for categories Supportive Services and PHP, 02/2011 deleted row (d) that asked for totals for all services. Now only totals in Section J and K need to match each other.
J. AGE AND GENDER OF BENEFICIARIES
Report the age and gender of the HOPWA clients and their beneficiaries.Category / Total
Male / Female
a. / Under 18
b. / 18 to 30 years
c. / 31 to 50 years
d. / 51 years and Older
e / Total
f. / Sum of Male and Female Beneficiaries / Total Beneficiaries
Please check: Row (f) should equal the total in Row (d)  (Green) in Section I above
Removed requirement for listing TBRA and STRMU separately by age and gender.
K. RACE AND ETHNICITY OF BENEFICIARIES
Report the race and ethnicity of the HOPWA clients and their beneficiaries. For Column 2, of the beneficiaries reported in column 1, report those that are ALSO Hispanic and Latino. Column 2 is a subset of Column 1.Race/Ethnicity / 
Total # Beneficiaries Served with Housing Assistance / 
Total # Beneficiaries also identified as
Hispanic or Latino
a. / White
b. / Black/African American
c. / Asian
d. / American Indian/Alaskan Native
e. / Native Hawaiian/Other Pacific Islander
f. / American Indian/Alaskan Native and White
g. / Asian and White
h. / Black/African American and White
i. / American Indian/Alaskan Native & Black African American
j. / Other Multi-Racial
k. / TOTAL BENEFICIARIES
Please check: Row (k)  should equal the total in Row (f) (Green) in Section J above
Removed requirement to report  and  by TBRA and STRMU separately.
L. HOUSEHOLD AREA MEDIAN INCOME
Please indicate the area median income for all unduplicated households served with HOPWA assistance. For information on the median income in your area, please refer to www.hud.gov.Percentage of area median income / # of HOPWA Households
a. / 0-30% of area median income (extremely low)
b. / 31-50% of area median income (very low)
c. / 51-80% of area median income (low)
d. / 61-80% of area median income (low)
e. / Total number of households
Please check: Row (e) should equal the total number of HOPWA clients under Part 2, Section F
DSHS is required to report these four levels on the Beneficiary. There were previously three levels in this chart on this report.
Removed (1) M. Household Monthly Income and (2) N. Mortgage Assistance
Part 3: Leveraged Information (To be completed in the 4th Quarter Report only)
M. LEVERAGED HOUSEHOLDS
Enter the total HOPWA-eligible households assisted with non-HOPWA funds. DO NOT include the HOPWA households receiving DSHS HOPWA funds, which have already been reported or other households receiving non-DSHS HOPWA funds. Leveraged households are clients of your agency and are eligible for HOPWA but are assisted by other funds or another housing assistance program.
· Leveraged Households are those served by your agency that would be eligible to receive HOPWA TBRA and/or STRMU but are receiving direct housing assistance (similar to HOPWA TBRA and STRMU) from a non-HOPWA source.
· These households must be receiving HOPWA Supportive Services and/or Permanent Housing Placement but are receiving direct housing assistance from a program other than HOPWA.
· Example: A client receiving HOME rental assistance but is receiving HOPWA Supportive Services.
· Must be connected to HOPWA to be leveraged. These are households served by your agency that also receive HOPWA Supportive Services and/or Permanent Housing Placement with their non-HOPWA housing assistance. This means leveraged households are receiving direct housing assistance (i.e. rental assistance or emergency assistance similar to HOPWA TBRA and STRMU) from a non-HOPWA source (i.e. State Services/Delivery, Ryan White, Housing Choice Voucher (Section 8), HOME, Shelter Plus Care, or any other direct housing funding source). For example, a client receives HOPWA Permanent Housing Placement but is receiving rental assistance from State Services funding in your agency.Housing Assistance / Total # of Additional Households
1. / Tenant-based Rental Assistance (i.e. rental assistance)
2. / Short-term Rent, Mortgage, and Utility Assistance (i.e. Emergency housing assistance)
N. LEVERAGED SOURCES BY PROGRAM ACTIVITY
Identify the amount and source(s) of cash or in-kind resources leveraged from other sources year-to-date, and used in delivery or operation of HOPWA activities. These funds include other funds used for on-site or other specific activities directly connected to serving HOPWA client households, at the activity or program level.
Make a good faith estimate of the sources of leveraged funds that you are aware of used to provide housing assistance, supportive services, and administration in the delivery of the HOPWA program. This is any money used to support HOPWA households that are non-HOPWA dollars. Supportive Services may include:
· adult day care and personal assistance
· alcohol and drug abuse services
· client management/advocacy/access to benefits and services
· childcare and other child services
· employment assistance and training
· health/medical/intensive care services (if approved, client records must conform with 24CFR 574.310)
· legal services
· life skills management (outside of case management)