P.O.W.E.R ATLANTA Atlanta Rising ~ Eligibility Form
Page 1
POWER ATLANTA's Atlanta Rising program has three requirements:
Client must reside in City of Atlanta,
Client must be in imminent danger of losing housing (within 14 days), and
Client's household income must fall below 80% HUD's income limit (AMI).
Pre - Qualification
My address is within the City of Atlanta
Yes
No
Are you in danger of losing your housing
within the next 14 days
?
Yes
No
Is your household yearly income under 80% AMI (see chart below)?
Yes
No
Unfortunately, you do not qualify for this program
.
Page 2
Please complete the following screening questions.
An POWER ATLANTA staff member will reach out to you within
3 working days
to complete a full intake.
Please provide a brief summary of your current living/housing situation, including where and with whom you are currently living, and describe your need for assistance from POWER ATLANTA.
Have you already been served with an eviction from the court?
Yes
No
Unknown
Do you know your Fulton County case number?
Yes
No
Civil Case Number
First Name
Last Name
Phone Number
Email Address
Is The Phone Number
Home (Landline)
Mobile
Work Phone
Do you give permission for POWER ATLANTA to contact you via Text Message (SMS) if necessary?
Yes
No
Street Address (do not include unit number)
Unit # if applicable
Zip Code
Please select...
30303
30305
30306
30307
30308
30309
30310
30311
30312
30313
30314
30315
30316
30317
30318
30319
30320
30322
30324
30326
30327
30331
30334
30336
30337
30342
30344
30354
30363
Household Information
What is your date of birth?
What is your marital status?
Please select...
Single
Married
Married, but Separated
Divorced
Widowed
How many adults are in your household?
How many children/minors are in your household?
Provide the legal first and last name(s) and Date of Birth(s) of all members in the household, this includes children/minors.
What is your total household income?
Do you have a disability?
Yes
No
Are you currently employed?
Yes
No
When do you expect your current housing situation to change or become unstable?
Please select...
Within 0–6 days
Within 7–14 days
Significant Changes or Housing Barriers
Within the last 60 days, have you experienced a sudden and significant loss of income (50% or more), including loss of employment or cash benefits, and/or an uncontrollable and significant increase in expenses (such as rent or medical expenses)?
Yes
No
Within the last 6 months, has there been a major change in your household composition that directly affects your ability to secure or maintain housing?
Examples: death of a household member, divorce/separation of the head of household, birth or addition of a child.
Yes
No
Is any household member age 55 or older?
Yes
No
Is anyone in the household a U.S. military veteran?
Yes
No
Does your household consist of 5 or more people?
Yes
No
Is anyone in the household currently pregnant?
Yes
No
Is the household headed by a single parent?
Yes
No
Does any household member have a disability that severely limits their ability to maintain housing independently?
Yes
No
Within the last 6 months, has any household member been discharged from an institution, such as a jail, hospital, or other residential institution?
Yes
No
Criminal History
Does any household member have a criminal record for any of the following?
Select all that apply.
Please select...
Arson
Drug dealing or drug manufacturing
Felony offense against a person
Felony offense against property
None of the above
Is any household member a registered sex offender?
Yes
No
Housing History
Has the head of household experienced homelessness one or more times within the last 3 years?
Yes
No
How many rental evictions has your household experienced within the last 3 years?
Please select...
4 or more
2–3
1
None
How many times has your household moved, excluding moves related to evictions, within the last year?
Please select...
4 or more moves
2–3 moves
1 move
None
Non-Cash Benefits
Do you or any household member currently receive non-cash benefits or assistance?
Non-cash benefits are government or community assistance that helps meet basic needs but is not paid directly as cash. Examples may include SNAP/food assistance, WIC, Medicaid/CHIP, housing assistance or vouchers, utility assistance, childcare assistance, or similar programs.
Yes
No
If yes, please list the type/source of each benefit and the monthly amount or value, if known.
Homelessness History
Within the last 3 years, have you experienced homelessness?
Yes
No
If yes, how many times have you experienced homelessness within the last 3 years?
If yes, approximately how many total months have you experienced homelessness within the last 3 years?
Health Insurance
Does your household currently have health insurance?
Yes
No
If yes, what type of health insurance coverage does your household have?
Please select...
Employer/work-sponsored insurance
Government-sponsored insurance
Other private insurance
Multiple types of coverage
Other / Unknown
Page 3
Consent Section
Consent for Participation in Research
Title
: Right at Home National Initiative
Lead Researcher(s)
: Dr. David Phillips, Dr. Jim Sullivan, Dr. Robert Collinson, and Dr. Grace Ortuzar
Study funding source
: Right at Home National Initiative
Partners for HOME is excited to partner with the University of Notre Dame’s Lab for Economic Opportunities (LEO) to study the impact of targeted homelessness prevention. This study is part of the Right at Home National Initiative, which seeks to implement and evaluate homelessness prevention programs across the country. You are eligible for this study because you are receiving services from a provider participating in the Right at Home National Initiative. We invite you to join the study and receive at least $20, with the opportunity to share your contact information to help us improve our social services.
Purpose of the Study
We hope you will participate in our research study to help us learn how rapid, flexible financial assistance and tailored support to stop housing loss can affect people’s lives. You will receive at least $20 dollars in the form of a gift card if you agree to participate in the study and fill out a short survey today. By participating, you will be one of several thousand people helping us learn how to better serve the community.
What will you be asked to do?
If you agree to participate in the study, some of your personal information and that of members of your household may be shared with the research team at the University of Notre Dame. This information may include names, dates of birth, contact information (such as phone number, email address, or mailing address), and Social Security or Individual Taxpayer Identification Numbers (if it’s already available for your local provider). Your personal information will be safely linked to other state and county systems such as Homeless Management Information System records, Medicaid records, public benefits use data, consumer reference data, credit reports (does not count against your credit score), as well as data from the criminal justice system and the Department of Education. We may also access records of how much money you earned from state Departments of Labor, the Internal Revenue Service, or the Census Bureau to see how earnings may change over time.
Your individual information will be used for research purposes only and will not be shared publicly
. The research team may access these data until the conclusion of the study, which will not be longer than 10 years. Afterwards, they will not access data without seeking out your consent again. This information is necessary to measure outcomes of program participants and help providers improve their services. You will also be asked to complete a short survey now.
We may also contact you in the future to participate in follow-up surveys. If you choose to participate in future follow-up surveys, you will receive an additional gift card of at least $20 to thank you for answering our questions. If you agree to participate in the study, we may contact you in the future using the phone number or email you provide (by call, text, or email) to invite you to complete a follow-up survey.
How will the research team keep my information safe?
Your privacy is important to your local provider and the research team. The research team will treat your data as confidential and protected information, meaning they will store your data securely and will use it only for the purposes of the study. They will only release results about groups of people in the study, so they will never reveal information about you individually.
At the end of the study, other researchers may use your data for future research, but this data will not include any individual information that will be traced back to you. LEO will make every effort to keep your information safe. Though confidentiality can’t be completely guaranteed, the risk of a breach of confidentiality is small.
Study participation is voluntary
If you choose not to participate in the study, you will not be asked to answer a survey, and you will not receive a gift card today. However, you may still access prevention services. Participation in the study will not limit your access to prevention funds, nor will it change your likelihood of receiving prevention funds. If you choose to participate in the study today, you can leave the study at a later date. Please consider that participating in the study could lead to more prevention programs being funded to help more people in the future.
The opportunity to receive prevention funds is randomly assigned as part of the Right at Home initiative. Those eligible for prevention funds will be randomly assigned, like the flip of a coin, to either receive prevention funds or not receive prevention funds. Whether you participate in the study will not affect your chance of receiving assistance.
Additional disclosures
Jim Sullivan is both a lead researcher on the study and a volunteer member of the board at Destination: Home, which started the targeted homelessness prevention program being studied.
I have more questions. Whom do I ask?
If you have any questions about prevention services, you can contact your case manager. You can also contact the research team by emailing atlanta-right-at-home@nd.edu. If you have any questions about your rights as a person in this study, you may talk to Notre Dame’s Office of Research Compliance at (574)-631-7432 or compliance@nd.edu.
I consent to participate in the research study
I do not consent to participate in the research study