Instructions: The Family Homeless Prevention and Assistance (FHPAP) Program grantee or sub-grantee (homeless prevention [HP] staff) should complete this assessment tool. The prospective participant should NOT complete this assessment tool. 

Background Information 	
The FHPAP Homelessness Prevention Assessment Tool is designed to assist FHPAP program staff with two functions: 
1.	To verify eligibility for homelessness prevention (HP) assistance, and 
2.	To identify the most vulnerable households most likely to experience homelessness if they do not receive assistance

In assisting with these two functions, the tool will support Minnesota’s goal in its attempt to prevent new cases of homelessness.

To administer the assessment tool, FHPAP staff (or others trained to administer the program) should check each box for which the condition or attribute is present in the household. Each checked box has a point value associated with it. After completing all questions, staff will add up the value of all checked boxes and assign a total score to the presenting household.  

As a screening tool, the questions are designed to identify households that are most likely to experience homelessness within the next month and for whom the experience of homelessness will pose the greatest risk for increased trauma, severe health consequences, and/or greatest degree of family instability.  

While no assessment tool can precisely predict the future, this tool is based upon research and program evaluation data that identifies conditions, characteristics, and attributes most closely associated with a future incidence(s) of homelessness. In addition, modifications to this tool have been made that incorporates feedback from Minnesota FHPAP prevention providers.

FHPAP Program Interventions (four options)
Light Touch Assistance: Services provided to eligible households under the “light touch” category include: 	
•	Limited case management
•	Relationship counseling
•	Assistance with housing referrals 	•	Landlord interventions
•	Referrals for public or community benefits and resources
•	Legal assistance 	
NOTE: Provision of financial assistance is not expected, although minimal financial assistance (no more than $100) may be provided in the form of bus passes, material assistance, or moving assistance. 	

One-time Assistance: Services provided to eligible households under the “one-time assistance” category include all those described under the Light Touch Assistance category, with the addition of: 	
•	One-time funding specifically targeting housing related costs 	
NOTE: Eligible one-time assistance funding includes one month of rent payment, rental deposit, utility payment, or utility deposit. 	

Short-term Assistance: Services include those identified in the Light Touch and One-time Assistance categories described above, but also include: 	
•	Time-limited rental assistance that helps a household pay for all or a portion of housing costs up to, but not to exceed, the equivalent of six months of rental assistance 	
NOTE: Although households being assisted with Short-term Assistance are eligible for up to six months of assistance, FHPAP providers will reassess the need for rental assistance every month throughout program enrollment.	

Medium-term Assistance: Services are the same as Short-term Assistance, but households are eligible for up to twenty-four months of rental assistance. 	

Homeless Prevention (HP) Staff: Complete the following three steps: 
Step 1: Determine Eligibility and Priority for Homelessness Prevention (HP) Assistance
NOTE: HP program staff: The following questions will help determine if the household is at imminent risk of homelessness and whether, without prevention assistance, the household will experience homelessness within the immediate upcoming month (e.g., either living in a place not meant for human habitation or residing in an emergency shelter or transitional facility intended for persons and households who are homeless).

In order to be eligible for HP assistance, the prospective applicant must provide evidence of a notice to vacate their current housing. 

HP staff should document eligibility evidence by securing a copy of the eviction notice, “pay or vacate” notice, or through written or oral communication with a friend/family member or the leaseholder/property owner/manager (whichever is applicable) with whom the prospective HP participant is currently living or from whom the prospective HP participant is renting. 

For a “doubled up” situation, the evidence can be an eviction notice or written or oral verification from a friend or family member with whom the prospective applicant is living. Written verification should be kept in the household file; oral verification should be documented in a case note.

Head of Household Name:      	
Date of Assessment:      	
Check each applicable condition that is true for the prospective HP participant (head of household). 	Check if Applicable	Point Value	
Step 1: Determine eligibility and priority for the homelessness prevention assistance 
household and whether the household is at imminent risk of literal homelessness. Without prevention assistance the household will experience literal homelessness within the next month (i.e. either living in a place not meant for human habitation or residing in an emergency shelter or transitional housing facility intended for persons and households who are homeless).	
Housing Status (select only one)			
If DOUBLED UP, the household has been told by the lease holder to vacate the unit. HP program staff has verified with the lease holder that the prospective HP participant is no longer welcome and must vacate. Prospective HP participant lacks the resources to secure alternative housing arrangements.		5	
If LEASE HOLDER, the household has received a notice to vacate by the property owner or manager or has received notice from the local building authority that the residence in which they reside is being condemned. HP program staff has verified with the property owner/manager/local building authority that the prospective HP participant has received notice to vacate. The prospective HP participant lacks the resources to secure alternative housing arrangements. Lease holder has previously experienced literal homelessness in the past two (2) years.		3	
If LEASE HOLDER, the household has received a notice to vacate by the property owner or manager or has received notice from the local building authority that the residence in which they reside is being condemned. HP program staff has verified with the property owner/manager/local building authority that the prospective HP participant has received notice to vacate. The prospective HP participant lacks the resources to secure alternative housing arrangements. Lease holder has NO previous experience of literal homelessness within the past two (2) years.		1	
Imminent loss of current housing. Loss of housing means the prospective household will experience literal homelessness – either on the streets or staying in an emergency shelter – within the specified period of time. Imminent loss of current housing must be verified with a ‘pay or vacate’ notice, ledger record of past due rent, or verification (verbal confirmation is sufficient) from the lease holder who is instructing the prospective HP participant to leave the housing.
(select only one)			
Actual housing loss expected within 7 days (1 week) 		5	
Actual housing loss expected within 14 days (2 weeks)		4	
Actual housing loss expected within 1 month		3	
Notice to vacate from the property manager/lease holder with expected loss of housing within 45 days		2	

TOTAL POINTS FROM STEP 1 (the above section)
	     	

STEP 2: Determine Targeting Priority Based on Vulnerabilities or Housing Barriers
NOTE: HP program staff: The following questions will help identify the barriers affecting the household’s ability to independently and quickly resolve housing and prevent homelessness from occurring in the imminent future. You will ask a series of questions of the prospective HP participant to determine the presence of current or past conditions that are most closely correlated with the incidence of homelessness. 

HP PROGRAM STAFF: Prior to asking the following questions, remind the prospective HP participant that some of the questions in this section ask about recent or past trauma. Reassure the prospective HP participant that before asking those questions, you will ask them if it is okay to proceed. (If the participant does not want to be asked, omit those questions, and do not score them.) 
Answer Y/N or check the box if applicable to the prospective HP applicant (head of household).	Check if Applicable	Point Value	
1.	Are you or is any member of your household a registered sex offender? 		5	
2.	Do you or does any member of your household have a criminal record or are you or is any member of your household involved in any legal proceeding in process for arson, drug dealing, manufacture of illegal drugs/illegal substances, possession and/or use of drugs/illegal substances, or any felony offense against persons or property? 		4	
3.	Are you a single parent who currently has shared or sole custody of your children? 		3	
4.	Do you have at least one dependent child under the age of six? 		3	
5.	Are you under the age of 25? 		3	
6.	Does your household have five people or more that cannot be housed in fewer than three bedrooms? 		1	
7.	Have you or another household member, been recently discharged (within the last six months) from an institution (such as a hospital, jail, etc.) after a stay of any length? 		3	
8.	Are you or a member of your household currently involved in protective services?		2	
9.	NOTE: HP PROGRAM STAFF: Inform the prospective HP participant that the next three questions ask about recent or past trauma. Ask the prospective HP participant if it is okay to proceed. If the participant does not want to be asked any of these questions, omit them and do not score.
a.	Within the last six months, has there been a household trauma or an event that directly affects your ability to secure and maintain housing? (Examples could include the death of a family member, separation or divorce from an adult partner, birth of a new child, etc.) 		3	
10.	Have you experienced adversity or housing disruptions during childhood? (Examples of childhood adversity could include homelessness, placement in foster care, eviction, refugee or immigrant to the U.S., or frequent moves [more than three in one year])		2	
 
11.	Are you currently fleeing or attempting to flee domestic violence? 
 		5	
Household annual or monthly gross income amount 			
12.	What is your current monthly or annual income?   $                                         
(HP staff select only one below)
•	$0
•	Less than 30% of federal poverty rate guidelines for household size (refer to the FY2020 federal poverty guidelines in the section that follows).
•	Between 31% and 50% of federal poverty rate guidelines for household size (refer to the FY2020 federal poverty guidelines in the section that follows). 
•	Between 51% and 200% of federal poverty rate/guidelines for household size (refer to the FY2020 poverty guidelines in the section that follows).	

 

	

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FY2021 Federal Poverty Guidelines*
FY2021 Federal Poverty Guidelines 	
1-Person 
Household	
2-Person 
Household	
3-Person 
Household	
4-Person 
Household	
5-Person Household	

Poverty Threshold     Annual    
                                      Monthly**                                            	
$12,880
$  1,073                    	
$17,420
$  1,452	
$21,960
$  1,830              	
$26,500
$  2,208	
$31,040
$  2,587	

Low                              Annual
51% - 200% Poverty Monthly     	
$25,760
$  2,147	
$34,840
$  2,903  	
$43,920
$  3,660                 	
$53,000
$  4,417	
$62,080
$  5,173	

Very Low                     Annual
31% - 50% Poverty    Monthly	
$   6,440
$      537	
$  8,710
$     726	
$10,980
$      915	
$13,250
$  1,104	
$15,520
$  1,293	

Extremely Low           Annual
0 – 30% Poverty        Monthly         	
$   3,864
$      322	
$  5,226
$     436	
$  6,588
$      549  	
$  7,950
$     663	
$  9,312
$     776	

*U.S. Department of Health and Human Services (HHS) federal poverty guidelines (FPG) are based on the Census Bureau’s most recent poverty thresholds and adjusting for Consumer Price Index (CPI-U). For families/households with more than five (5) persons, add $4,540 annually for 100% FPG, $9,080 annually for 200% FPG, $2,270 annually for 50% FPG, and $1,362 annually for 30% FPG. 
**Monthly amounts are rounded to the nearest dollar.	
13.	Has there been a sudden and/or significant loss of income, including loss of employment and/or cash benefits within the last 60 days, OR an uncontrollable and significant increase in non-discretionary expenses within the last 60 days? 		3	
Prior rental evictions for the head of household at any time in the past 			
14.	 Have you had any prior rental evictions?  			
15.	If yes to #14, how many prior rental evictions have you had? (select only one)

a.	One prior rental eviction 

b.	Two to three prior rental evictions

c.	Four or more prior rental evictions 	

	

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History of homelessness for head of household (street/shelter/transitional housing) 			
16.	Have you ever been homeless? 			
17.	If yes to #16, how many episodes of homelessness have you experienced (choose the best applicable answer:

a.	One prior episode of homelessness in the past three years 

b.  Two to three episodes of homelessness in the past three years 

b.	Four or more episodes of homelessness OR a total of at least 12 months within the past three years 	

	

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1.		
		
1.				
TOTAL POINTS FROM STEP 2 (the above section)	     	

TOTAL POINTS FROM STEP 1 AND STEP 2	     	
Once the total points from Steps 1 and 2 have been added, use the following chart to determine the prospective HP participant’s threshold level (threshold impact based on scoring the prospective participant’s responses):
HP Target Score Range	Possible Threshold Impact	Prospective HP Participant’s Score
(Total from Steps 1 and 2)	
Urban	Rural			
0 – 12	0 – 10	Eligible for Light Touch Assistance 	     	
13 – 15	11 – 13	Eligible for One-time Assistance	     	
16 – 20	14 – 17	Eligible for Short-term Assistance	     	
21 +	18 +	Eligible for Medium-term Assistance 	     	
           *FHPAP state administrators will identify FHPAP grantees as either “urban” or “rural” 
       
STEP 3: Document Local Policy Priorities  
The local priorities below were identified by FHPAP prevention providers; however, priorities may vary by region. Using local data, FHPAP grantees can consult with their advisory committee and modify the questions below, as needed, in order to align with their local priorities. In addition, Minnesota Housing may define other housing barriers or attributes most likely to impact a household’s ability to quickly secure housing and resolve homelessness independently. If included, these other scored attributes will align with local policy priorities.  

FHPAP regions may choose to take Step 3 points into account when determining if the household qualifies for FHPAP assistance. For example, if two households have the same Step 1 and Step 2 combined score, grantees may choose to provide assistance to the household that scores the highest in Step 3. The policy of whether to include Step 3 points should be determined by the FHPAP advisory committee and/or their local Continuum of Care (CoC), and the implementation of this policy should be consistent within their FHPAP region. 
Does any household member have a disability that substantially impedes the ability to maintain housing independently?		1	
Does any household member identify as an ethnic, cultural, or racial minority group that has historically experienced unfair treatment in the provision or administration of public benefits or services?		1	
Is any household member a senior adult (aged 55 or older)?		1