D R A F T III
(for GC review 7/14/14)
A Way Home For Tulsa
Written Standards for Providing
Continuum of Care Assistance
Table of Contents
- Common assessment and referral system
- Evaluating individuals' or families' eligibility for assistance
- Determining and prioritizing eligibility based on local characteristics
- Determination of housing stabilization and/or relocation type, amount and duration
- Determination of participant's share of costs
- Determination of participant's length of time for rental assistance
- Local coordination of shelters and service providers
- Compliance with CoC standards of operation
- CoC Policy on evaluating ESG projects
- Centralized information and referral
Attachment A – Vulnerability Index for Tulsa Assistance ("VITA") with User Guide
1
D R A F T III
(for GC review 7/14/14)
In conjunction with the recipients of ESG program funds within the Tulsa area and in
accordance with the Homeless Emergency Assistance and Rapid Transition to Housing Act of
2009 ("HEARTH Act") amendment to the McKinney-Vento Homeless Assistance Act and the
Department of Housing and Urban Development's ("HUD's") Interim Rule, the Continuum of
Care known as A Way Home for Tulsa ("Continuum" or "CoC" or "AWH4T") adopts the following
guidelines. These guidelines will govern the application of the coordinated (or "common")
assessment system that has been created to provide an initial, comprehensive assessment of
the needs of individuals and families for housing and homeless support services. The CoC's
common assessment system's primary emphasis is on providing proper referrals for emergency
shelter, Rapid Re-Housing ("RRH"), Transitional Housing ("TH") and Permanent Supportive
Housing ("PSH"). Pertaining to the latter, the Housing First concept will apply. Based on the
CoC regulations at 24 CFR Subpart B § 578.7, the policies described herein apply to all members
of the Continuum unless specific reference to Emergency Solutions Grant- ("ESG") funded
programs' requirements is made.
Coordinated (or "common") Assesment and Referral System The common assessment and referral system developed by the Continuum of Care known as A
Way Home for Tulsa ("CoC" or "Continuum" or "AWH4T"), in conjunction with local ESG-funded
programs' input, was created to assess the needs of homeless individuals and families or those
at risk of homelessness and match those needs to the most appropriate housing or service
alternatives. All CoC- and ESG-funded programs are required to utilize the CoC common
assessment system. If attempts at diversion or prevention do not solve a person's or family's
housing problem when initially presenting to the homeless service provider and the participant
has been homeless no more than one hundred eighty-one (181) cumulative days (or stays), the
intake staff at the "no wrong door" point of entry can then proceed with an interview of the
participant to ascertain the best immediate housing options within the Continuum. The
Vulnerability Index for Tulsa Assistance ("VITA") will be utilized as part of the initial screening
process to gather enough information concerning the stability and acuity of the presenting
individual (see Attachment A)1. The interviewer will ask the participant a series of questions
from the VITA that are designed to identify the conditions affecting the individual's ability to
secure or maintain housing. Information regarding such domains as housing history/status,
1
The Continuum has opted to implement its Common Assessment process in phases based initially on whether or
not the presenter is alone (i.e., an individual) versus being part of a family and how long the presenter has been
homeless. The criteria for common assessment under subsequent phases is outlined below:
 Phase I - (immediate implementation upon Council approval) would require the initial assessment of
individuals (regardless of age) no later than one hundred eighty-one (181) cumulative days/stays from initial
presentment
 Phase II - (implementation after one year of operation under Phase I) would require initial assessments of
individuals aged 18-24
 Phase III - (implementation after one year of operation under Phase II) would require that initial assessments
be offered to families using Phase II timeframes of no later than sixty-one (61) days
 Phase IV - (implementation after one year of operation under Phase III) would require initial assessments of
individuals and families no later than sixty-one (61) cumulative days/stays from initial presentment.
2
D R A F T III
(for GC review 7/14/14)
physical health, mental health, substance abuse and other general risk factors will be gathered
to assemble the risk profile necessary to assess the participant's vulnerability and level of need.
All information from the participant will be self-reported, although surveyors conducting the
interviews can also register their own impressions of the presenting participant's condition on
the VITA. Should the participant refuse to answer the questions posed in the VITA, the
interviewer will note that fact in HMIS. The intake staff will then have the discretion to do
either one of the following:
 Complete the surveyor observation questions contained within the VITA without participant
input
 Refer the participant to another homeless service provider
 Elect to initiate an intervention.
Should the presenting participant(s) be fleeing or attempting to flee domestic violence, dating
violence, sexual assault, stalking or human trafficking, the non-victim service providers in the
Continuum will refer the victim to an appropriate shelter program that specifically targets such
groups. Until the protection of one of these organizations can be assured, special care will be
taken to ensure that the victim is afforded a secure environment within the intake provider's
organization and that the security of the participant's identity and privacy are given special
consideration. This could include reserving a private area within the accepting agency's
location or the creation of a special track within the assessment framework that is specifically
designed for domestic violence victims.
3
D R A F T III
(for GC review 7/14/14)
Evaluating Individuals or Families Eligible for Assistance –
Eligibility to receive assistance under all CoC-funded programs will be based on the guidelines
outlined by HUD, initially by determining if the individual or family qualifies as “homeless” as
defined in the HEARTH Act of 2009, § 103 or as "at-risk of homelessness". Evaluation and
eligibility policies and procedures are developed in accordance with the Continuum's common
assessment requirements set forth under § 578.7(a)(8) of HUD's Interim Rule that governs the
regulatory implementation of the CoC program.
All homeless services, including diversion and prevention, will be provided on the basis of the
relative need of each presenter. To receive homeless prevention assistance, the applicant must
be “at risk of homelessness" at the time assistance is requested. To receive RRH, emergency
shelter or street outreach assistance, HUD funded providers must ensure that the applicant is
“homeless” at the time assistance is requested. As mandated in the most recent Notice of
Funding Availability, AWH4T will "prioritize those who are identified as most in need (e.g., those
who have been living on the street the longest, homeless households with children living in
unsheltered situations, those that are considered most medically vulnerable, etc.) for
placement into appropriate housing."
The members of the Continuum and local ESG-funded program recipients will work together to
identify which eligible persons could benefit the most from assistance. Upon initial evaluation,
the type and amount of assistance deemed appropriate will be offered to ensure the
individual's or family’s needs are met to regain housing stability. A homeless service provider
may develop and follow its own internal policies and procedures that further outline the
evaluation methods for the project it is administering. When determining the annual income of
an individual or family, the homeless service provider must use the standards for calculating
annual income under 24 CFR 5.609 and 24 CFR 5.611(a). Other resources like Federal, State,
local, and private assistance available in obtaining housing stability may also be considered.
When determining eligibility for short- and medium-term rental assistance, no program
participant who is receiving tenant-based rental assistance or living in a housing unit receiving
project-based rental assistance or operating assistance through other public sources is eligible,
except for a one-time payment for up to six (6) months of rental arrearages and late fees, if
applicable, on the ESG program tenant’s portion of the rent. The participant’s eligibility for
assistance, and the types and amounts of assistance to be given, will be evaluated at least every
three (3) months for individuals or families receiving homeless prevention assistance and
annually for those receiving rapid re-housing assistance.
4
D R A F T III
(for GC review 7/14/14)
Local Coordination of Shelters and Service Providers –
The CoC network of homeless service providers will provide coordinated services that minimize
any duplication of services in order to serve the most participants possible. Tulsa’s Homeless
Services Network ("HSN") and Continuum members meet regularly to discuss issues such as
evolving trends, challenges and funding fluctuations in an effort to facilitate coordination
between local homeless service providers and shelters. A program called "Fresh Start", created
to assist coordination between local shelters, public officials, religious organizations and other
entities that interact with homeless individuals and families, also meets regularly to discuss
specific cases and share information necessary to aid the homeless and those at risk of
homelessness. In addition, the Continuum will, to the maximum extent practicable, coordinate
and integrate information with outside agencies and organizations that provide similar services
or mainstream support within the community.
5
D R A F T III
(for GC review 7/14/14)
Determining & Prioritizing Eligibility Based on Local Characteristics CoC members will carefully assess how their own program resources can best be used to
prevent and end homelessness. Information gained from HMIS data, staff observations,
available funding streams, and a community-wide assessment of the need for and availability of
interventions to serve individuals and families experiencing homelessness will be used to
inform these assessment efforts. Assistance may be provided for those program participants
who meet the RRH criteria of homeless under the HEARTH definition. Homeless support
services are offered to all other program participants that are at risk of homelessness.
Rapid re-housing and homeless prevention assistance will be provided in accordance with the
housing relocation and stabilization services requirements in 24 CFR § 578.53 or the short- and
medium-term rental assistance requirements in 24 CFR § 578.37.
Homeless individuals and families that are identified as belonging to special populations, such
as domestic violence victims, youth or veterans, will be provided additional assistance at local
emergency shelters with programs specifically created to serve them. Those shelters that serve
these special populations will prioritize the delivery of services based on the particular needs of
the specific population being served, as outlined in those agencies’ policies.
The CoC and ESG network members work together to establish standard criteria for
prioritization based on the local characteristics in the Tulsa area. Characteristics recently
identified in this area that were most prevalent were unemployment, health problems
(physical, mental and dental), single adults with and without children, criminal records, lack of
transportation and a history of substance abuse treatment. Through its collaboration with the
Homeless Services Network ("HSN"), the CoC follows the Housing First philosophy for its RRH
programs, as identified in Opening Doors: the Federal Strategic Plan to End Homelessness, in
that, it considers it a priority to connect people to housing with the resources necessary to
sustain housing and to facilitate the Tulsa community's accomplishment of its RRH goals of
ending homelessness, reducing emergency shelter stays, limiting recidivism and documenting
outcomes.
A review of the participant's needs may result in one of the following possible outcomes:
 Shelter stay – a short term stay (usually overnight) with minimal support services or
financial assistance
 Transitional housing – Housing, the purpose of which is to facilitate the movement of
individuals and families experiencing homelessness to permanent housing within twentyfour (24) months or longer. To be qualified for TH, program participants must have signed a
lease or occupancy agreement with the HUD-funded agency that is for a term of at least
one month and that ends in twenty-four (24) months. The lease or agreement cannot be
extended without HUD approval.
 Rapid Rehousing – CoC funds may be used to provide supportive services and short-term
and/or medium-term tenant-based rental assistance to help a homeless individual or family,
6
D R A F T III

(for GC review 7/14/14)
with or without disabilities, move as quickly as possible into permanent housing and
achieve stability in housing. RRH project participants must meet with a case manager not
less than once per month, as set forth in the Interim Rule's § 578.37(a)(1)(ii)(F), except
where prohibited by the Violence Against Women Act ("VAWA") and the Family Violence
Prevention and Services Act ("FVPSA"). A full range of supportive services can be provided
for up to six (6) months after the rental assistance stops. Although program participants
may receive short-term or medium-term rental assistance under the HUD CoC programs
that match the time frames set forth in the ESG programs, the supportive services available
to program participants receiving RRH assistance under the CoC program are not limited to
housing relocation and stabilization services as they are in the ESG program.
Permanent supportive housing – While the term "permanent housing" means communitybased housing without a designated length of stay and includes both permanent supportive
housing and rapid re-housing, PSH is housing in which supportive services are provided to
assist homeless persons with a disability to live independently. And, just as for permanent
housing, the PSH program participant must be the tenant on a lease for a term of at least
one year (renewable in at least monthly increments) and the lease may only be terminable
for cause. The chronically homeless within these populations will always be given priority.
7
D R A F T III
(for GC review 7/14/14)
Determination of Participant’s Share of Costs –
The Continuum's homeless service providers work closely with participants to determine what
portion of rent and utility costs, if any, the participants will be required to pay. Fee structures
are based on challenges associated with homelessness in Tulsa, the availability of resources
within the community, and existing housing and economic conditions. Each program
participant on whose behalf rental assistance payments are made must pay a contribution
toward rent in accordance with § 3(a)(1) of the US Housing Act of 1937 (42 U.S.C. 1437
A(a)(1). Further, 24 CFR Subpart D § 578.37 (a)(ii)(B) stipulates that when the participant's
share of the rent is being determined, a monthly utility allowance using standards set by the
local housing authority may be considered part of the rent. More restrictive guidelines may
be placed on the portion of assistance by the agency administering the grant.
8
D R A F T III
(for GC review 7/14/14)
Determination of Participant’s Responsibility and Length of Time for Rental
Assistance –
Subject to program funding availability, participants eligible for homeless support services and
RRH rental assistance may receive assistance for a maximum of twenty-four (24) months of
assistance in a three (3) year period. Short-term assistance may be used for up to three (3)
months' rent and medium-term assistance may be used for no more than twenty-four (24)
months' rent. Accrued rental arrearages for ESG-funded programs may be paid for up to six (6)
months' worth of rent, including any late fees on those arrearages. Guidelines to determine
changes in assistance amounts that may become necessary over time will be established in
conjunction with the homeless service providers administering the program. Both tenant- and
project-based rental assistance is allowed for ESG programs while only tenant-based programs
are allowed under CoC programs. Tenant-based participants must have a lease that is for a
period of at least one year, regardless of the length of rental assistance, that is renewable for a
minimum term of one month and is terminable only for cause.
Eligible RRH financial assistance may include the following:







Rent or utility obligations in arrears up to six (6) months for ESG funded programs only per
ESG Interim Rule (24 CFR §576.106 (a)(3))
Application fees
Security deposits in an amount not to exceed two (2) months' of rent
Utility deposits and monthly utility payments. For ESG- funded programs only, utility
arrearages may be paid.
Rent for up to twenty-four (24) months provided the participant is not receiving any other
federal, state or local rent subsidies. ESG-funded programs may also pay delinquent rent or
fees.
Moving costs
Other supportive services allowed under CoC-funded programs per 24 CFR § 578.53
9
D R A F T III
(for GC review 7/14/14)
Determination of Housing Stabilization and/or Relocation Type, Amount and
Duration –
The amount of assistance provided will be determined by the homeless service provider and
the participant upon review of funding allocations. Housing stabilization and/or relocation
assistance may be provided in the form of security deposits, utility payments, moving
assistance and case management depending on the form of assistance agreed upon by the
participant and homeless service provider. If security deposits are paid, they may be equal to
no more than two (2) months' rent. The last month’s rent may be paid to the landlord not to
exceed the amount of one month’s rent. Utility payments may be paid for up to twenty-four
(24) months of service, including up to six (6) months of utility payments in arrears for ESGfunded programs. When paying participants' moving costs, payment of temporary storage may
be paid for up to three (3) months after the date that ESG assistance begins. Housing stability
case management assistance for ESG-funded programs may not exceed thirty (30) days during
the period the program participant is seeking permanent housing and may not exceed twentyfour (24) months during the period the program participant is living in permanent housing.
More restrictive guidelines may be placed on the duration of assistance by the agency
administering the grant.
10
D R A F T III
(for GC review 7/14/14)
Compliance with CoC standards of operations –
The Continuum will consult with local ESG funded programs to determine how to best allocate
CoC funds for each program year and will develop and update performance standards for, and
evaluate outcomes of, projects and activities assisted by ESG funds. This cooperative form of
service delivery necessitates close communication and coordination with mainstream programs
for housing, health, social services, employment, education and youth for which homeless
families and individuals or those at risk of homelessness may be eligible.
With the exception of victim service providers, CoC- and EGS-funded homeless service
providers will participate in the ShareLink Homeless Management Information System
("HMIS"), the CoC designated information system, to report data for their respective programs
according to the HUD HMIS Data Standards. Victim service providers will use a separate
database to collect participant-level data without interfacing or sharing data with HMIS. ESG
recipients submit quarterly reports to the CoC to review outcomes and inform funding
priorities.
AWH4T organizations will designate staff persons responsible for ensuring that dependent
children are enrolled in school and connected to the appropriate services within the
community, including early childhood education programs such as Head Start, Part C of the
Individuals with Disabilities Education Act and McKinney-Vento education services. All CoCfunded members will provide housing for the entire family regardless of the age of its children
and will actively collaborate with local school districts and early childhood education providers
to identify homeless households with children to ensure they understand their eligibility for
educational services. In alignment with McKinney-Vento requirements, homeless service
providers will notify families of the ability of school districts to provide transportation services
to keep the children in their school of origin and will assist in the coordination of this service for
the children as appropriate. ESG funded program entities may be involved in this effort.
Federal Fair Housing policies with regard to equal access to housing in HUD programs
regardless of sexual orientation or gender identity as found in 24 CFR Parts 5, 200, 203, 236,
400, 570, 574, 882, 891 and 982 and the current NOFA will be followed.
11
D R A F T III
(for GC review 7/14/14)
CoC Policy on Evaluating ESG Projects The CoC consults with the City of Tulsa Grants Division in the establishment of ESG priorities,
policies and performance standards. In compliance with HEARTH regulations and the City of
Tulsa Ordinance #22813 dated 2/13/2013, the CoC and the ESG-funded programs in the City of
Tulsa will:
 Coordinate regarding homeless needs and ensure that the approved policies meet the
needs, priorities, goals and outcome measures of the local homeless services providers.
 Mutually consult with each other regarding allocation of funding, developing
performance standards and evaluating outcomes of ESG assisted projects.
A CoC representative appointed by the Mayor of the City of Tulsa will serve on the City's HUD
Community Development Committee that is tasked with assessing local community housing
needs and setting the priorities and standards for allocation of ESG funds.
12
D R A F T III
(for GC review 7/14/14)
Centralized Information and Referral Organizations may refer participants to 2-1-1 Helpline when appropriate to access services like
its Housing Referral Guide that can ease the burdens faced by those that are homeless or at risk
of homelessness and possibly defer or prevent a homeless event altogether. 2-1-1 Helpline is
also the central point of entry and screening for the VA-funded Supportive Services for Veteran
Families ("SSVF") providing homeless prevention assistance for veterans. 2-1-1 conducts initial
screening and service matching and makes follow-up appointments with SSVF Housing
Navigator staff for further assessment and verification.
Pathways is a coordinated case management system targeting long-term and chronically
homeless persons in Tulsa. This program focuses on a Housing First philosophy and rapid rehousing of individuals, utilizing an intensive, inter-agency case management approach to
quickly coordinate needed support services while accessing housing. Case managers and
homeless outreach staff make referrals to the Pathways HUB, the centralized administrative
infrastructure for this program. The Pathway HUB staff conducts intake and assessment,
confirms eligibility and has final admission authority for entry into the program.
13
D R A F T III
(for GC review 7/14/14)
Attachment A
HOUSING VITA
Housing Vulnerability Index for Tulsa Assistance
INDIVIDUAL HOUSING VITA
vi·ta noun \ˈvē-tə, ˈvī-tə\
1.
2.
A short account (biographical sketch) of a person's life or résumé.
Vita (Latin and Italian for LIFE).
The HOUSING VITA is a common assessment tool that will measure and assess a homeless person’s life in order
to promote housing for life in the City of Tulsa. This tool is intended to end chronic homelessness in Tulsa and
surrounding areas in Oklahoma.
HOUSING 4 LIFE
AWH4T
*4 shelters would be using this tool*
14
D R A F T III
INTERVIEWER’S NAME:
(for GC review 7/14/14)
AGENCY
DATE:
TIME:
LOCATION:
FIRST NAME:
LAST NAME:
SERVICE POINT #
NICKNAME(S):
DATE OF BIRTH:
SOCIAL SECURITY #:
AGE
_
INDIVIDUAL’S LANGUAGE PREFERENCE:
INDIVIDUAL HAS CONSENTED TO PARTICIPATE:
INDIVIDUAL’S SIGNATURE FOR CONSENT:
YES
NO
DATE INDIVIDUAL SIGNED CONSENT:
WITNESS SIGNATURE:
DATE:
VULNERABILITY INDEX
VARIABLE #1--HISTORY OF HOUSING & HOMLESSNESS
*Have you been homeless every day for the past 6 months?*
*Have you had 180 shelter stays in the past year?*
If YES to either question, then this individual has experienced at least 180 sheltered or
quantifiably unsheltered days or stays over the past 12 months and they meet the AWH4T
definition of long term homelessness. If YES, this individual will be immediately considered more
vulnerable than others.
If YES TO EITHER QUESTION ABOVE, score will automatically be PLUS FIVE (5)
*Have you been homeless every day for the past 12 months or had 4 separate occasions of being
homeless in the last 3 years?*
If YES, score will automatically be PLUS TEN (10)
SUBTOTAL FOR HISTORY OF HOUSING & HOMELESSNESS
(SUBTOTAL CANNOT BE GREATER THAN 15 IN THIS AREA—IT IS POSSIBLE THAT ALL 3 ANWERS IN THIS
AREA COULD BE ANSWERED AS “YES”)
15
D R A F T III
(for GC review 7/14/14)
VARIABLE #2--TRI-MORBITITY DETERMINATION FACTORS: (Note to surveyor: The individual MUST
have at least one condition in each of the following domains for tri-morbidity to exist.
1.MENTAL HEALTH QUALIFIERS: Plus one (1) for each checked box.
Have you:
Ever been diagnosed with any mental health condition?
Been treated or receiving counseling for any mental health issues?
Been taken to the hospital against your will for mental health reasons?
MENTAL HEALTH SYMPTOMATIC: IF MENTAL HEALTH CONDITION(S) EXIST
Are
PLUS FIVE (5) if answer is NO
2.CHRONIC MEDICAL CONDITION QUALIFIERS: Plus one (1) for each checked box.
Are you dealing with or ever been diagnosed with any of the following health conditions:
Kidney Disease/ESRD or Dialysis
Liver Disease/Cirrhosis/End Stage Liver Disease
HIV+/AIDS
Asthma/COPD/Emphysema
Diabetes
Chronic Heart Conditions
Cancer
Hepatitis B or C
Tested Positive for TB
CHRONIC HEALTH SYMPTOMATIC: IF CHRONIC HEALTH CONDITION(S) EXIST
Are you currently being treated for chronic health.
PLUS FIVE (5) if answer is NO
3.SUBSTANCE ABUSE QUALIFIERS: Plus one (1) for each checked box
Are you dealing with any of the following issues:
Ever abused alcohol or reported use
Ever abused drugs or reported use
Used intravenous drugs and/or shared needles
Been treated for alcohol or drug abuse (COURT ORDERED OR NOT)
Consumed alcohol every day for the last 30 days
SUBSTANCE ABUSE SYMPTOMATIC: IF SUBSTANCE ABUSE EXIST
IF ALCOHOL ABUSE CHECKED- Are you currently being treated or attending meetings for alcohol abuse.
PLUS FIVE (5) if answer is NO
IF DRUG ABUSE CHECKED-Are you currently being treated or attending meetings for drug abuse.
PLUS FIVE (5) if answer is NO
SUBTOTAL FOR TRI-MORBIDITY DETERMINATION FACTORS
(SUBTOTAL IN THIS AREA CAN RANGE FROM ZERO (0) TO 37 ONLY)
*NOW YOU ARE GOING TO DETERMINE IF TRI-MORBIDITY EXISTS* If yes plus two (2)
IS THERE AT LEAST ONE CHECKED BOX IN EACH OF THE THREE CATEGORIES ABOVE?
TOTAL SCORE ON THIS PAGE CANNOT EXCEED 39, LIST TOTAL SCORE FOR THIS PAGE
16
D R A F T III
(for GC review 7/14/14)
VARIABLE #3--RISK FACTORS: Plus one (1) for each checked box:
Threatened or been in fear for your life in the past six (6) months?
Intellectual Disability—Ever been diagnosed with a learning disability
Trauma
History of felony conviction(s) and/or history of prison stay(s)
-24 years of age
T)
ree (3)
months
UNSHELTERED: IF YES PLUS FIVE (5)
Are you currently living in an encampment, car, park, etc?
RISK FACTORS SYMPTOMATIC: IF RISK FACTOR CONDITION(S) EXIST PLUS FIVE (5) IF NO
Are you currently being treated for any risk factors?
SUBTOTAL FOR RISK FACTORS
(SUBTOTAL IN THIS AREA CANNOT EXCEED +26)
VARIABLE #4—VETERAN STATUS: IF yes plus two (2).
HAVE YOU SERVED ONE DAY OR MORE ACTIVE SERVICES IN THE MILITARY BEYOND TRAINING?
IF YES: PLEASE PUT “+2” IN THE BOX BELOW
IF NO: PLEASE PUT “+0” IN THE BOX BELOW
TOTAL SCORE AFTER THIS AREA WILL BE “+2” OR “+0”
DISCHARGE TYPE: HONORABLE OTHER THAN HONORABLE DISHONORABLE BAD CONDUCT
ARE YOU ELIGIBLE /ENROLLED IN VETERANS HEALTH CARE SERVICES?
(SUBTOTAL IN THIS AREA CANNOT EXCEED +2)
TOTAL SCORE ON THIS PAGE CANNOT EXCEED 28, LIST TOTAL SCORE FOR THIS PAGE
17
D R A F T III
(for GC review 7/14/14)
VARIABLE #5—OBSERVATION ONLY--DO NOT ASK: Plus five (5) for each yes.
1. Surveyor—Do you believe this individual is not able to feed, bathe, groom, dress, or toilet themselves without
assistance?
_____________________________________________________________________________________
2. Surveyor—Do you detect signs or symptoms of a serious health condition?
_____________________________________________________________________________________
3. Surveyor—Do you detect signs or symptoms of alcohol or drug abuse?
_____________________________________________________________________________________
4. Surveyor—Do you detect signs or symptoms of any mental illness or compromised cognitive functioning?
IF YES IS ANSWERED TO ALL FOUR (4) OBSERVATION ONLY QUESTIONS PLUS FIVE (5).
SUBTOTAL FOR SURVEYOR OBSERVATION
(SUBTOTAL IN THIS AREA CANNOT EXCEED +25)
_____________________________________________________________________________________
(THIS IS A 107 POINT VULNERABILITY INDEX EXAMINING CHRONIC HOMELESS, RISK FACTORS,
TRI-MORBIDITY, SYMPTOMATIC, AND VETERAN STATUS IN THE CITY OF TULSA AND SURROUNDING
AREAS IN OKLAHOMA.)
DOMAIN:
SCORE:
HISTORY OF HOUSING & HOMLESSNESS
TRI-MORBIDITY DETERMINATION FACTORS
RISK FACTORS
VETERAN STATUS
SURVEYOR OBSERVATION
0 TO 15
1 TO 39
1 TO 26
0 OR 2
0 TO 25
TOTAL: (PLEASE ADD ALL SCORES HERE)
18
D R A F T III
(for GC review 7/14/14)
How to complete the Housing Vulnerability Index for Tulsa Assistance (HOUSING VITA)
Purpose of Form
The Housing VITA is a self-reporting common assessment tool that will measure and assess a homeless
person’s life in order to promote housing for life in the City of Tulsa. This tool is intended to end chronic
homelessness in Tulsa.
Completing Basic Information:
 Complete the basic information.
 Ask the participant to sign and date if they consent.
 The surveyor should sign as the witness on consent.
 If the individual does not wish to participate. The Case Manager will enter refused in HMIS and
the assessment is over.
 If the individual gives consent please proceed with the Housing VITA.
Variable #1
 In Variable #1 you will be determining the length of homelessness and if the participant meets the
HUD definition of chronic homelessness.
 Any answer that is NO or MAYBE does NOT receive a score.
 Case Manager needs to check HMIS for shelter stays.
 If participant answers MAYBE Case Manager needs to investigate.
 Please score Yes answers as requested in Variable #1.
Variable #2
 In Variable #2 you will be able to determine if Tri-Morbidity exist. If there is at least one checked
box in each section of the Variable #2 Tri-Morbidity exists.
 Please score each checked box as requested in Variable #2
 Symptomatic question(s) - Please score this question if participant is symptomatic in this area. (If
applicable YES answer will not receive a score).
Variable #3
 In Variable #3 you will be determining risk factors.
 Please score each checked box as requested in Variable #3
 Symptomatic question(s) - Please score this question if participant is symptomatic in possible
symptomatic areas. (If applicable YES answer will not receive a score).
Variable #4
 In Variable #4 you will be determining Veteran Status.
 Any I Don’t Know and NO answers will not receive a score.
Variable #5
 In Variable #5 you will give your observation of the participant. This will determine if the
participant is at a greater risk than he/she is self reporting.
 These questions are NOT to be asked. They are for Observation Only.
 Please score Yes answers as requested in Variable #5; NO answers will not receive a score.
SCORING
Once the Housing VITA has been completed you will total up the score to determine how vulnerable the
individual is.
You will write the scoring on the Housing VITA and enter the outcome into HMIS in the designated area.
19