SSM Scoring Tool by xiaohuicaicai

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									Instructions

The Self-Sufficiency Matrix is a measurement tool that captures, at a point in time, an individual's
dependence on public assistance. There are several components of this scoring tool.

This scoring tool should be used in conjunction with the Self-Sufficiency Matrix Assessment Standards,
which can be found on the forms page of the HMIS website at:
    https://www.hmisscc.org/html/hmis_forms.html

Scoring Sheet
The Scoring Sheet is the primary worksheet used to score a client's self-sufficiency and consists of a set of
yes/no questions associated with each domain. It should be completed by a case manager or other service
provider, not by the client being assessed. To use the Scoring Sheet:

   1. Begin by saving the file under another name so as not to overwrite your master file. To do so, go to
   File > Save As and browse to the folder in which you want to save the client's matrix scores.


   2. Type the Client's Name and the date of assessment into the blue cells at the top of the worksheet.

   3. The basis of who is assessed for each domain is indicated in parenthesis next to the domain's title.
   The questions for some domains should be answered in reference to the individual, and other domains
   should be assessed in reference to the individual's household.

   4. Beginning with question A in each domain, answer the yes/no questions by placing a "x" in the blue
   cell that corresponds with a yes/no answer for each question. For example, when assessing in the
   Income domain, if the client has income, type x in cell D9.


   5. Column F, CM Next Step, provides instructions after a question is answered. Follow the instructions
   to receive the most accurate score. For example, after answering yes to question 1A, the prompt states,
   "Ask 1B," so question 1B should be the next question answered.

   NOTE: It is imperative that you follow the instructions exactly after answering each question in
   order to get an accurate score. You may need to skip questions or not answer all of the questions.

   6. When the instructions prompt "Section complete…" there should be a score for that domain in
   column A, Score. This domain requires no further questions to be answered and the case manager
   should begin assessing the next domain.

   7. Continue to answer questions as prompted until all domains are assessed.

Some domains include definitions or references to other worksheets with more detailed explanatory
information. The assessor should pay special attention to these definitions and corresponding worksheets
(described below).

The Scoring Sheet may be printed for a case file. Alternately, the Score Summary worksheet can be printed
for case file.

Score Summary
When questions are answered on the Scoring Sheet resulting in a score, that score will be populated on the
Score Summary. The Score Summary sheet is printable as 1 page for case files, and the domains are listed
in the same order as they appear in HMIS to facilitate efficient data entry.

HPRP Eligibility
This worksheet functions in the same was as the Score Summary but only includes the 8 domains required
for initial HPRP eligibility screening.

Federal Poverty Guidelines
This worksheet should be used when assessing a household's income. Assessment should be completed
based on gross income. This worksheet lists the maximum income a household can have (based on
household size) and fall below 200% of the federal poverty guidelines.

Housing Definitions

This worksheet includes the definitions that should be considered when assessing in the Housing domain.

ADLs
This worksheet lists the Activities of Daily Living which should be considered when assessing in the Life
Skills domain.

Matrix
This worksheet contains the original Self-Sufficiency Matrix implemented in Santa Clara County.

Scoring Sheet Logic
While the preferred method for establishing a self-sufficiency score is by using the auto-calculating Scoring
Sheet worksheet, the Scoring Sheet Logic worksheet should be used if the score needs to be developed
manually and not within the Excel file. The numbers or letters in the yes/no columns for each domain's
question correspond to the score that should be assigned or the next question that should be asked,
respectively.

Some domains, such as Legal, are more complicated in that different combinations of answers to multiple
questions are required to produce an accurate score. Users who intent to score self-sufficiency manually on
a regular basis should contact the the Self-Sufficiency Matrix Advisory Group for more detailed training and
explantion.
   Form SSM01 - 9/16/2010                                                                                       Self-Sufficieny Matrix Assessment - Page 3 of 26



Client's Name:                                                                     Assessment Date:

  Score                       Domain (Who is assessed)                                                                  CM Next Step


                   Click here for the FPG table
                                                                                Mark the appropriate answers with x.
               1 Income (Household)
                                                                                   Yes          No                     Begin assessment
                A Does the household have income?

                B Is the household's income greater than or equal to
                  200% of Federal Poverty Guidelines (FPG - see link
                  above for FPG )?
                C Does the household exhibit appropriate spending
                  (able to meet basic needs)?
                D Does the household need assistance (outside of own
                  income) to meet basic needs?
                E Does the household have discretionary income and
                  the ability to save?




                   Adequate pay is greater than or equal to the Living Wage
                   Determination (LWD), published annually by the City of San
                   Jose's Office of Equity Assurance.

                   The LWD as of 7/1/2010 is $12.94 per hour with health
                   benefits, $14.19 without health benefits.
                                                                                Mark the appropriate answers with x.
               2 Employment (Individual)
                                                                                   Yes          No                     Begin assessment
                A Does the client have a job?

                B Is the job full time (32+ hours per week)?

                C Does the job pay adequately (see definition above)?

                D Is the full-time job regular (not temporary)?




                   Click here for the Housing domain definitions
                                                                                Mark the appropriate answers with x.
               3 Housing (Household)
                                                                                   Yes          No                     Begin assessment
                A Is the household unhoused or at imminent risk of
                  losing their housing?
                B Is the housing stable and affordable (see link above
                  for definitions of stable and affordable re: housing)?
                C Is the housing adequate (see link above for definition
                  of housing adequacy)?
                D Is the housing subsidized?
   Form SSM01 - 9/16/2010                                                                                            Self-Sufficieny Matrix Assessment - Page 4 of 26



Client's Name:                                                                          Assessment Date:

  Score                       Domain (Who is assessed)                                                                       CM Next Step
                                                                                     Mark the appropriate answers with x.
               4 Food (Household)
                                                                                        Yes          No                     Begin assessment
                A Is the household's primary food source shelters or
                  soup kitchens?
                B Does the household have food AND the means/ability
                  to prepare it?
                C Can the household meet their basic food needs
                  without food stamps?
                D Can the household meet their basic food needs
                  without any assistance (e.g., food bank, charitable
                  food boxes, family help, etc.)?
                E Can the household satisfy any food need?




                                                                                     Mark the appropriate answers with x.
               5 Childcare (Household)
                                                                                        Yes          No                     Begin assessment
                A Does the household include children ages 0-11
                  years?
                B Does the household have the childcare (e.g.,
                  childcare center, family/household arrangement, etc.)
                  they need?
                C Is childcare available that the household can access?

                D Is the childcare reliable, affordable, and adequate?

                E Is the childcare subsidized?

                 F Can the household select quality childcare of their
                   choice?




                   Note: Eligible = eligible for public (K-12) school, through the
                   child's 18th birthday; this definition of eligible should be
                   applied to each question in this domain

                                                                                     Mark the appropriate answers with x.
               6 Children's Education (Household)
                   See note above                                                       Yes          No        See domain note and begin assessment
                A Does the household include children who are eligible
                  for school?
                B Are all eligible children enrolled in school?

                C Are all eligible children attending classes?

                D Are all eligible children attending classes most of the
                  time?
                E Are all eligible children attending class regularly and
                  making progress?
   Form SSM01 - 9/16/2010                                                                                           Self-Sufficieny Matrix Assessment - Page 5 of 26



Client's Name:                                                                         Assessment Date:

  Score                       Domain (Who is assessed)                                                                      CM Next Step


                   Note: Clients who completed education outside of the U.S.
                   should be assessed based on how that education is
                   generally recognized in the U.S.
                                                                                    Mark the appropriate answers with x.
               7 Adult Education (Individual)
                   See note above                                                      Yes          No        See domain note and begin assessment
                A Does the client have a high school diploma or GED?

                B Is literacy and/or language a serious barrier to
                  employment?
                C Does the client have the education/literacy/language
                  skills to function effectively in society (i.e., manage
                  daily living and employment tasks)?
                D Has the client completed education/training needed
                  to become employable?




                   Significant legal issues for purposes of this matrix are those
                   that would currently impact, in a negative way, the client's
                   housing or employment qualifications. This could include
                   immigration, driving without a valid driver's
                   license/insurance, etc.
                                                                                    Mark the appropriate answers with x.
               8 Legal (Individual)
                                                                                       Yes          No                     Begin assessment
                A Has the client ever had serious legal problems (such
                  as a felony, significant legal issues [see definition
                  above], or probation/parole)?
                B Does the client have an outstanding warrant?

                C Has the client ever been on probation or parole?

                D Is the client currently on probation or parole?

                E Did the client complete probation or parole in the past
                  12 months?
                F Is the client fully compliant with probation or parole?

                G Has the client had any new charges in the past 12
                   months?
                H Have the charges received in the past 12 months
                   been resolved (no further action needed)?
                 I Has the client ever been convicted of a felony?

                J Has the client ever had a history of significant legal
                  issues other than probation/parole or a felony (see
                  definition above)?
                K Does the client have any other unresolved significant
                  legal issues?
                L Is the client working on a plan to resolve the
                  unresolved significant legal issues?
                M Has the client recently resolved significant legal
                  issues?
   Form SSM01 - 9/16/2010                                                                                  Self-Sufficieny Matrix Assessment - Page 6 of 26



Client's Name:                                                                Assessment Date:

  Score                      Domain (Who is assessed)                                                              CM Next Step
                                                                           Mark the appropriate answers with x.
               9 Health Care (Household)
                                                                              Yes          No                     Begin assessment
                A Does the household have medical coverage?

                B Does anyone in the household have an immediate
                  health care need?
                C Is anyone in the household without medical
                  coverage?
                D Is the household on publicly funded health coverage
                  (e.g., Medi-Cal, Medicaid, Medicare without additional
                  insurance supplement, Healthy Families, etc.)?

                E Does the cost of health insurance strain the
                  household's budget?




                   Click here for examples of ADLs
                                                                           Mark the appropriate answers with x.
              10 Life Skills (Individual)
                                                                              Yes          No                     Begin assessment
                A Can the client perform some Activities of Daily Living
                  (ADLs - see link above for explanation of ADLs)
                  without assistance?
                B Can the client perform most ADLs without
                  assistance?
                C Can the client perform all ADLs without assistance?

                D Is the client able to perform beyond ADLs (e.g., care
                  of others, care of pets, child rearing, health
                  management, etc.) for self and family?


                                                                           Mark the appropriate answers with x.
              11 Mental Health (Individual)
                                                                              Yes          No                     Begin assessment
                A Does the client have symptoms of mental illness?

                B Is the client a danger to self or others?

                C Does the client have significant difficulty (4 or more
                  times per week) functioning due to symptoms of
                  mental illness?
                D If the client's symptoms of mental illness impair
                  functioning about 3 times per week, select No.

                   If the client's symptoms of mental illness impair
                   functioning about 1 time per week, select Yes.
   Form SSM01 - 9/16/2010                                                                                          Self-Sufficieny Matrix Assessment - Page 7 of 26



Client's Name:                                                                        Assessment Date:

  Score                       Domain (Who is assessed)                                                                     CM Next Step


                   A person who is seriously dependent persists in the use of
                   alcohol or other drugs despite problems related to use of
                   the substance; use is compulsive and repetitive.
                                                                                   Mark the appropriate answers with x.
              12 Substance Abuse (Individual)
                                                                                      Yes          No                     Begin assessment
                A Is the client seriously dependent (see definition
                  above) on drugs or alcohol?
                B Does the client need hospitalization, inpatient
                  treatment, or institutional living?
                C Does the client show evidence of recurrent social,
                  emotional, or physical problems associated with drug
                  or alcohol use?
                D Is the client free from problems associated with drug
                  or alcohol use during the past six months?
                  (Answering "Yes" includes clients with no history of
                  substance abuse.)




                   Note 1: Support includes emotional, financial, and material
                   support; this definition of support should be applied to each
                   question in this domain.

                   Note 2: This domain should be assessed based on
                   relationships within the household and other family and
                   close friends.

                   Note 3: Abuse or neglect should be reported immediately to
                   the proper authorities.
                                                                                   Mark the appropriate answers with x.
              13 Family Relations (Household)
                   See notes above                                                    Yes          No       See domain notes and begin assessment
                A Does the household have any type of support from
                  family or close friends?
                B Is abuse or neglect present (see Note 3 above)?

                C Do family/friends seek to improve negative behaviors
                  within the relationship?
                D Do family/friends have the ability to offer all types of
                  support?
                E Do family members communicate and offer strong
                  support to each others' efforts?
                F Is the support network expanding?
   Form SSM01 - 9/16/2010                                                                                        Self-Sufficieny Matrix Assessment - Page 8 of 26



Client's Name:                                                                      Assessment Date:

  Score                      Domain (Who is assessed)                                                                    CM Next Step
                                                                                 Mark the appropriate answers with x.
              14 Mobility (Individual)
                                                                                    Yes          No                     Begin assessment
                A Does the client have a car?

                B Is the car operable?

                C Is the car reliable, affordable, and predictable?

                D Does the client use public transportation?

                E Does the client have insurance and a valid driver's
                  license?
                F Does the client use the car?

                G Is the car always available?

                H Does the car meet the client's basic travel needs?

                 I Does the client use public transportation?

                J Does the client have a bus pass that the client does
                  not pay for?
                K Does the client have access (it exists in or will come
                  to the area in which the client lives) to public or
                  private transportation other than his/her own car?
                L Is the transportation reliable, affordable, and
                  predictable?
                M For the client's needs, is the transportation limited
                  and/or inconvenient?
                N Is the transportation readily available?




                   Note: The client should primarily be assessed on his/her
                   level of involvement with formal and informal group,
                   associations, volunteerism, community organizations, etc.
                   rather on his/her social skills.
                                                                                 Mark the appropriate answers with x.
              15 Community Involvement (Individual)
                   See note above                                                   Yes          No        See domain note and begin assessment
                A Is the client in survival mode that is limiting their
                  ability to be involved?
                B Is the client socially isolated or lacking the social skills
                  and/or motivation to become involved?
                C Is the client new to the community?

                D Does the client know how to become involved in the
                  community?
                E Is the client involved in the community?

                 F Does the client have barriers (such as transportation
                   or childcare issues) that prevent him/her from being
                   actively involved in the community?
   Form SSM01 - 9/16/2010                                                                                     Self-Sufficieny Matrix Assessment - Page 9 of 26



Client's Name:                                                                   Assessment Date:

  Score                       Domain (Who is assessed)                                                                CM Next Step

                   Note: This assessment is related to the client's housing
                   environment. It may include, but is not limited to, the
                   presence of any domestic violence.
                                                                              Mark the appropriate answers with x.
              16 Safety (Individual)
                   See note above                                                Yes          No        See domain note and begin assessment
                A Is the client's housing environment safe and stable
                  (able or likely to continue with regard to safety) in the
                  long term, with low or no lethality?
                B Does the housing environment have high lethality
                  and lack temporary protection?
                C Is temporary protection necessary and available?

                D If safety is minimally adequate and safety planning is
                  essential, mark No.

                   If safety is present but uncertain in the future and
                   safety planning is important, mark Yes.



                   Note: State law requires that evidence of child abuse be
                   reported immediately to the proper authorities.
                                                                              Mark the appropriate answers with x.
              17 Parenting Skills (Individual)
                   See note above                                                Yes          No        See domain note and begin assessment
                A Does the household include children under the age of
                  18?
                B Are there safety concerns regarding parenting skills
                  (see Note above)?
                C Are the client's parenting skills well developed (parent
                  is a positive role model, maintains child's
                  structure/routine, and is involved in child's
                  education)?
                D Are the client's parenting skills adequate (parent
                  usually employs age-appropriate parenting
                  techniques)?
                E Are the client's parenting skills apparent (parent
                  makes some effort to apply age-appropriate
                  parenting techniques, but application is inconsistent)?

                 F Are the client's parenting skills minimal (parent is
                   generally disengaged, discipline consists primarily of
                   yelling, blaming, shaming)?


                                                                              Mark the appropriate answers with x.
              18 Credit History (Individual)
                                                                                 Yes          No                     Begin assessment
                A Does the client have any outstanding judgments,
                  evictions, bankruptcy, or foreclosure?
                B Has the client implemented a documented credit
                  repair plan for the judgments, etc.?
                C Does the client have any debt in collections?

                D Has the client implemented a documented credit
                  repair plan for the debt in collections?
                E Has the client ever had credit (credit cards, loans,
                  etc.)?
                F Does the client have good credit with a manageable
                  debt ratio?
Form SSM02 - 9/16/2010



                            Self-Sufficiency Matrix Assessment

                           Client Name:
                         Assessment Date:


                            Domain (listed in HMIS order)       Score
                             3 Housing
                             2 Employment
                             1 Income
                             4 Food
                             5 Child Care
                             6 Children's Education
                             7 Adult Education
                             9 Health Care
                            10 Life Skills
                            13 Family Relations
                            14 Mobility
                            15 Community Involvement
                            17 Parenting Skills
                             8 Legal
                            11 Mental Health
                            12 Substance Abuse
                            16 Safety
                            18 Credit

                                                Total Score:            0
                                              Total Possible:           0
                                          Self-Sufficiency %:

                              Score based on 0 domains assessed.

                             Assessment incomplete! Please assess
                            the remaining 18 domains for an accurate
                                   self-sufficiency percentage!

                               Note: This self-sufficiency assessment
                                 measures a client's point-in-time
                                   reliance on public assistance.
Form SSM02 - 9/16/2010



                            Self-Sufficiency Matrix Assessment
                                    for HPRP Eligibility

                           Client Name:
                         Assessment Date:


                            Domain (listed in HMIS order)       Score
                             3 Housing
                             2 Employment
                             1 Income
                             5 Child Care
                            10 Life Skills
                             8 Legal
                            16 Safety
                            18 Credit

                                                Total Score:            0
                                              Total Possible:           0
                                          Self-Sufficiency %:

                              Score based on 0 domains assessed.

                              Assessment incomplete! Please assess
                             the remaining 8 domains for an accurate
                                   self-sufficiency percentage!

                               Note: This self-sufficiency assessment
                                 measures a client's point-in-time
                                   reliance on public assistance.
Click here to go back to the Scoring Sheet

Federal Poverty Guidelines
Source: US Department of Health and Human Services Poverty Guidelines (August 2010)

SCC Standard: Assess based on gross annual household income

   Persons in      200% of poverty
   household          guideline
       1              $21,660
       2              $29,140
       3              $36,620
       4              $44,100
       5              $51,580
       6              $59,060
       7              $66,540
       8              $74,020

For households with more than 8 persons, add $7,480 for each additional person.
Click here to go back to the Scoring Sheet

Housing Domain Definitions

Stable = able or likely to continue; transitional housing is not considered stable

Affordable = household pays no more than 30% of gross income for housing

Housing Adequacy
The following factors should be taken into account with regard to housing adequacy:
-Legal security of tenure
-Availability of services, materials, facilities, and infrastructure
-Affordability
-Habitability
-Accessibility
-Location
-Cultural adequacy
Source: UN Committee on Economic, Social and Cultural Rights
Click here to go back to the Scoring Sheet

Activities of Daily Living (ADLs)

Basic ADLs (self-care tasks necessary for fundamental functioning)
-Bathing
-Dressing and undressing
-Eating
-Transferring from bed to chair, and back
-Voluntarily control urinary and fecal discharge
-Using the toilet
-Walking (not bedridden)

Instrumental ADLs (not necessary for fundamental functioning, but enable the individual to live independently within a communi
-Light housework
-Preparing meals
-Taking medications
-Shopping for groceries or clothes
-Using the telephone
-Managing money
live independently within a community)
                                                                 Self-Sufficiency Matrix
DOMAIN            1                              2                             3                           4                            5
Incom e           No income                      Inadequate income and/or      Can meet basic needs        Can meet basic needs and     Income is sufficient, well
                                                 spontaneous or                with subsidy; appropriate   manage debt without          managed; has
                                                 inappropriate spending        spending                    assistance                   discretionary income and
                                                                                                                                        is able to save
Em ploy m ent     No job                         Temporary, part-time or Employed full time;               Employed full time with      Maintains permanent
                                                 seasonal; inadequate pay, inadequate pay; few or          adequate pay and             employment with
                                                 no benefits               no benefits                     benefits                     adequate income and
                                                                                                                                        benefits
Hous ing          Homeless or threatened         In transitional, temporary In stable housing that is      Household is in safe,        Household is safe,
                  with eviction                  or substandard housing; safe but only marginally          adequate subsidized          adequate, unsubsidized
                                                 and/or current             adequate                       housing                      housing
                                                 rent/mortgage payment is
                                                 unaffordable (over 30%
                                                 of income)

Food              No food or means to            Household is on food          Can meet basic food         Can meet basic food          Can choose to purchase
                  prepare it. Relies to a        stamps                        needs, but requires         needs without assistance     any food household
                  significant degree on                                        occasional assistance                                    desires
                  other sources of free or
                  low-cost food
Childcare         Needs childcare, but none      Childcare is unreliable or Affordable subsidized          Reliable, affordable         Able to select quality
(0=n/a)           is available/accessible        unaffordable, inadequate childcare is available, but      childcare is available, no   childcare of choice
                  and/or child is not eligible   supervision is a problem   limited                        need for subsidies
                                                 for childcare that is
                                                 available

                  One or more eligible           All eligible children         Enrolled in school, but     Enrolled in school and      All eligible children
Education         children not enrolled in       enrolled in school, but       one or more children only   attending classes most of   enrolled and attending on
(0=n/a)           school                         one or more children not      occasionally attending      the time                    a regular basis and
                                                 attending classes             classes                                                 making progress
Adult Education   Literacy problems and/or       Enrolled in literacy and/or   Has high school             Needs additional            Has completed
                  no high school                 GED program and/or has        diploma/GED                 education/training to       education/training
                  diploma/GED are serious        sufficient command of                                     improve employment          needed to become
                  barriers to employment         English to where                                          situation and/or to resolve employable. No literacy
                                                 language is not a barrier                                 literacy problems to        problems
                                                 to employment                                             where they are able to
                                                                                                           function effectively in
                                                                                                           society
                                                              Self-Sufficiency Matrix
DOMAIN             1                           2                             3                             4                                5
Legal              Current outstanding         Current charges/trial         Fully compliant with          Has successfully                 No active legal issues in
                   tickets or warrants or      pending; noncompliance        probation/parole terms;       completed                        more than 12 months
                   other serious unresolved    with probation/parole;        past non-violent felony       probation/parole within          and/or no
                   legal issues                legal issues impacting        convictions; working on       past 12 months, no new           felony/significant
                                               housing qualifications        plan to resolve other legal   charges filed; recently          legal/criminal history
                                                                             issues                        resolved other legal issues

Health Care        No medical coverage with No medical coverage and          Some members (e.g.         All members can get                 All members are covered
                   immediate need               great difficulty accessing   children) on Medi-Cal, but medical care when                   by affordable, adequate
                                                medical care when            adults lack coverage       needed, but may strain              health insurance
                                                needed. Some household                                  budget
                                                members may be in poor
                                                health
Life S kills       Unable to meet basic         Can meet a few but not       Can meet most but not all Able to meet all basic               Able to provide beyond
                   needs such as hygiene,       all needs of daily living    daily living needs without needs of daily living               basic needs of daily living
                   food, activities of daily    without assistance           assistance                 without assistance                  for self and family
                   living
Mental Health      Danger to self or others; Recurrent mental health         Mild symptoms may be          Minimal symptoms that            Symptoms are absent or
                   recurring suicidal           symptoms that may affect     present but are transient;    are expectable responses         rare; good or superior
                   ideation; experiencing       behavior, but not a          only moderate difficulty      to life stressors; only slight   functioning in wide range
                   severe difficulty in day-to- danger to self/others;       in functioning due to         impairment in functioning        of activities; no more than
                   day life due to              persistent problems with     mental health problems                                         every day problems or
                   psychological problems       functioning due to mental                                                                   concerns
                                                health symptoms

S ubs tance Abus e Meets criteria for severe   Meets criteria for            Use within last 6 months;     Client has used during last No drug use/alcohol abuse
                   abuse/dependence;           dependence;                   evidence of persistent or     6 months, but no            in last 6 months
                   resulting problems so       preoccupation with use        recurrent social,             evidence of persistent or
                   severe that institutional   and/or obtaining              occupational, emotional       recurrent social,
                   living or hospitalization   drugs/alcohol; withdrawal     or physical problems          occupational, emotional,
                   may be necessary            or withdrawal avoidance       related to use (such as       or physical problems
                                               behaviors evident; use        disruptive behavior or        related to use; no
                                               results in avoidance or       housing problems);            evidence of recurrent
                                               neglect of essential life     problems have persisted       dangerous use
                                               activities                    for at least one month
                                                                Self-Sufficiency Matrix
DOMAIN            1                              2                             3                           4                           5
Fam ily Relations Lack of necessary support      Family/friends may be         Some support from           Strong support from         Has healthy/expanding
                  form family or friends;        supportive, but lack          family/friends; family      family or friends.          support network;
                  abuse (DV, child) is           ability or resources to       members acknowledge         Household members           household is stable and
                  present or there is child      help; family members do       and seek to change                                      communication is
                  neglect                        not relate well with one      negative behaviors; are     efforts                     consistently open
                                                 another; potential for        learning to communicate
                                                 abuse or neglect              and support

Mobility            No access to                 Transportation is available   Transportation is available Transportation (including Transportation is readily
                    transportation, public or    (including bus), but          (including bus) and         bus) is generally accessible available and affordable;
                    private; may have car that   unreliable, unpredictable,    reliable, but limited       to meet basic travel needs car is adequately insured
                    is inoperable                unaffordable; may have        and/or inconvenient;
                                                 care but no insurance,        drivers are licensed and
                                                 license, etc                  minimally insured

Com m unity         Not applicable due to        Socially isolated and/or no Lacks knowledge of ways    Some community                 Actively involved in
Inv olv em ent      crisis situation; in         social skills and/or lacks  to become involved or      involvement (church,           community (church, etc.)
                                                 motivation to become        new to community           advisory group, support
                                                 involved                                               group), but has barriers
                                                                                                        such as transportation,
                                                                                                        childcare issues
S afety             Home or residence is not     Safety is threatened,        Safety is minimally       Home is safe, however,         Home is apparently safe
                    safe, lethality is high      temporary protection is      adequate, safety planning future is uncertain, safety    and stable
                                                 available, lethality is high is essential              planning is important

Parenting S kills   Parenting skills are       Parenting skills are            Parenting skills are        Parenting skills are        Parenting skills are well
(0=n/a)             lacking and there is no    minimal and there is            apparent but not            adequate                    developed
                    extended family support    limited extended family         adequate
                                               support
Credit His tory     Outstanding judgements Outstanding judgements              No credit history or debt Moderate credit rating        Good credit/manageable
                    or bankruptcy/foreclosure or bankruptcy/foreclosure        in collections with a credit                            debt ratio
                    with no credit repair plan with a credit repair plan       repair plan
                                               or debt in collections with
                                               no a credit repair plan
  Form SSM01 - 9/16/2010                                                   Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 19 of 26



              Domain (Who is assessed)


1 Income (Household)
                                                                Yes   No
 A Does the household have income?
                                                                 b    1
B Is the household's income greater than or equal to
  200% of Federal Poverty Guidelines (FPG)?                      c    2
C Does the household exhibit appropriate spending (able
  to meet basic needs)?                                          d    2
D Does the household need assistance (outside of own
  income) to meet basic needs?                                   e    3
E Does the household have discretionary income and
  the ability to save?                                           5    4

   Click here for the FPG table




2 Employment (Individual)
                                                                Yes   No
 A Does the client have a job?
                                                                 b    1
 B Is the job full time (32+ hours per week)?
                                                                 c    2
C Does the job pay adequately (see definition below)?
                                                                 d    3
D Is the full-time job regular (not temporary)?
                                                                 5    4

   Adequate pay is greater than or equal to the Living Wage
   Determination (LWD), published annually by the City of San
   Jose's Office of Equity Assurance.

   The LWD as of 7/1/2010 is $12.94 per hour with health
   benefits, $14.19 without health benefits.




3 Housing (Household)
                                                                Yes   No
A Is the household unhoused or at imminent risk of
  losing their housing?                                          1    b
B Is the housing stable and affordable (see link below for
  definitions of stable and affordable re: housing)?             c    2
C Is the housing adequate (see link below for definition
  of housing adequacy)?                                          d    3
D Is the housing subsidized?
                                                                 4    5

   Click here for the Housing domain definitions
  Form SSM01 - 9/16/2010                                                          Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 20 of 26



               Domain (Who is assessed)


4 Food (Household)
                                                                      Yes   No
A Is the household's primary food source shelters or
  soup kitchens?                                                       1    b
B Does the household have food AND the means/ability
  to prepare it?                                                       c    1
C Can the household meet their basic food needs
  without food stamps?                                                 d    2
D Can the household meet their basic food needs
  without any assistance (e.g., food bank, charitable
  food boxes, family help, etc.)?                                      e    3
E Can the household satisfy any food need?
                                                                       5    4




5 Childcare (Household)
                                                                      Yes   No
 A Does the household include children ages 0-11 years?
                                                                       b    n/a
B Does the household have childcare (e.g., childcare
  center, family/household arrangement, etc.)?                         d    c
C Is childcare available that the household can access?
                                                                       d    1
D Is the childcare reliable, affordable, and adequate?
                                                                       e    2
 E Is the childcare subsidized?
                                                                       f    3
 F Can the household select quality childcare of their
   choice?                                                             5    4




6 Children's Education (Household)
   See note below                                                     Yes   No
 A Does the household include children under the age of
   18?                                                                 b    n/a
 B Are all eligible children enrolled in school?
                                                                       c    1
C Are all eligible children attending classes?
                                                                       d    2
D Are all eligible children attending classes most of the
  time?                                                                e    3
E Are all eligible children attending class regularly and
  making progress?                                                     5    4

   Note: Eligible = eligible for public school, through the child's
   18th birthday; this definition of eligible should be applied to
   each question in this domain
  Form SSM01 - 9/16/2010                                                            Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 21 of 26



               Domain (Who is assessed)


7 Adult Education (Individual)
   See note below                                                   Yes     No
 A Does the client have a high school diploma or GED?
                                                                      c       b
 B Is literacy and/or language a serious barrier to
   employment?                                                        1       2
 C Does the client have the education/literacy/language
   skills to function effectively in society (i.e., manage
   daily living and employment tasks)?                                d       3
 D Has the client completed education/training needed to
   become employable?                                                 5       4


   Note: Clients who completed education outside of the U.S.
   should be assessed based on how that education is
   generally recognized in the U.S.




8 Legal (Individual) - score conditional to multiple
   questions                                                        Yes     No
 A Has the client ever had serious legal problems (such
   as a felony, significant legal issues [see definition
   below], or probation/parole)?                                      b       5
 B Does the client have an outstanding warrant?
                                                                      1       c
 C Has the client ever been on probation or parole?
                                                                      d       g
 D Is the client currently on probation or parole?
                                                                      f       e
 E Did the client complete probation or parole in the past
   12 months?                                                        g        g
 F Is the client fully compliant with probation or parole?
                                                                      i      2
                               max score/probation or parole
 G Has the client had any new charges in the past 12
   months?                                                           h        i
 H Have the charges received in the past 12 months been
   resolved (no further action needed)?                               i       2
                                  max score/new charges
  I Has the client ever been convicted of a felony?
                                                                      j       j
 J Has the client ever had a history of significant legal
   issues (see definition below)?                                    k      score
 K Does the client have any unresolved significant legal
   issues?                                                            l      m
 L Is the client working on a plan to resolve the
   unresolved significant legal issues?                               3       2
 M Has the client recently resolved significant legal
   issues?                                                          score   score
                                     max score/legal history

   Significant legal issues for purposes of this matrix are those
   that would currently impact, in a negative way, the client's
   housing or employment qualifications.
   Form SSM01 - 9/16/2010                                                Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 22 of 26



              Domain (Who is assessed)


9 Health Care (Household)
                                                              Yes   No
 A Does the household have medical coverage?
                                                               c    b
 B Does anyone in the household have an immediate
   health care need?                                           1    2
 C Is anyone in the household without medical coverage?
                                                               3    d
 D Is the household on publicly funded health coverage
   (e.g., Medi-Cal, Medicaid, Medicare without additional
   insurance supplement, Healthy Families, etc.)?
                                                               3    e
 E Does the cost of health insurance strain the
   household's budget?                                         4    5




10 Life Skills (Individual)
                                                              Yes   No
 A Can the client perform some Activities of Daily Living
   (ADLs - see link below for explanation of ADLs)
   without assistance?                                         b    1
 B Can the client perform most ADLs without assistance?
                                                               c    2
 C Can the client perform all ADLs without assistance?
                                                               d    3
 D Is the client able to perform beyond ADLs (e.g., care of
   others, care of pets, child rearing, health management,
   etc.) for self and family?                                  5    4


   Click here for examples of ADLs




11 Mental Health (Individual)
                                                              Yes   No
 A Does the client have symptoms of mental illness?
                                                               b    5
 B Is the client a danger to self or others?
                                                               1    c
 C Does the client have significant difficulty (4 or more
   times per week) functioning due to symptoms of
   mental illness?                                             2    d
 D If the client's symptoms of mental illness impair
   functioning about 3 times per week, select No.

    If the client's symptoms of mental illness impair
    functioning about 1 time per week, select Yes.             4    3
  Form SSM01 - 9/16/2010                                                      Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 23 of 26



              Domain (Who is assessed)


12 Substance Abuse (Individual)
                                                                   Yes   No
 A Is the client seriously dependent (see definition below)
   on drugs or alcohol?                                             b    c
 B Does the client need hospitalization, inpatient
   treatment, or institutional living?                              1    2
 C Does the client show evidence of recurrent social,
   emotional, or physical problems associated with drug
   or alcohol use?                                                  3    d
 D Is the client free from problems associated with drug
   or alcohol use during the past six months?
   (Answering "Yes" includes clients with no history of
   substance abuse.)                                                5    4


   A person who is seriously dependent persists in the use of
   alcohol or other drugs despite problems related to use of the
   substance; use is compulsive and repetitive.




13 Family Relations (Household)
   See notes below                                                 Yes   No
 A Does the household have any support from family or
   friends?                                                         b    1
 B Is abuse or neglect present (see Note 3 below)?
                                                                    1    c
 C Do family/friends seek to improve negative behaviors
   within the relationship?                                         d    2
 D Do family/friends have the ability to offer support?
                                                                    e    2
 E Do family members communicate and offer strong
   support to each others' efforts?                                 f    3
 F Is the support network expanding?
                                                                    5    4


   Note 1: Support includes emotional, financial, and material
   support; this definition of support should be applied to each
   question in this domain.

   Note 2: This domain should be assessed based on
   relationships with family and friends.

   Note 3: Abuse or neglect should be reported immediately to
   the proper authorities.
  Form SSM01 - 9/16/2010                                                       Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 24 of 26



               Domain (Who is assessed)


14 Mobility (Individual)
                                                                    Yes   No
 A Does the client have a car?
                                                                     b    i
 B Is the car operable?
                                                                     c    i
 C Is the car reliable, affordable, and predictable?
                                                                     e    d
 D Does the client use public transportation?
                                                                     i    2
 E Does the client have insurance and a valid driver's
   license?                                                          g    f
 F Does the client use the car?
                                                                     2    i
 G Is the car always available?
                                                                     h    5
 H Does the car meet the client's basic travel needs?
                                                                     4    i
  I Does the client use public transportation?
                                                                     j    3
 J Does the client have a bus pass that the client does
   not pay for?                                                     m     k
 K Does the client have access (it exists in or will come to
   the area in which the client lives) to public or private
   transportation other than his/her own car?                        l    1
 L Is the transportation reliable, affordable, and
   predictable?                                                     m     2
 M Is the transportation limited and/or inconvenient?
                                                                     3    No
 N Is the transportation readily available?
                                                                     5    4




15 Community Involvement (Individual)
   See note below                                                   Yes   No
 A Is the client in survivial mode that is limiting their ability
   to be involved?                                                   1    b
 B Is the client socially isolated or lacking the social skills
   and/or motivation to become involved?                             2    c
 C Is the client new to the community?
                                                                     3    d
 D Does the client know how to become involved in the
   community?                                                        e    3
 E Is the client involved in the community?
                                                                     f    3
 F Does the client have barriers (such as transportation
   or childcare issues) that prevent him/her from being
   actively involved in the community?                               4    5

   Note: The client should primarily be assessed on his/her
   level of involvement with formal and informal group,
   associations, volunteerism, community organizations, etc.
   rather on his/her social skills.
  Form SSM01 - 9/16/2010                                                    Self-Sufficieny Matrix Assessment Scoring Sheet Logic - Page 25 of 26



              Domain (Who is assessed)


16 Safety (Individual)
   See note below                                               Yes   No
 A Is the client's housing environment safe and stable
   (able or likely to continue) in the long term, with low or
   no lethality?                                                 5    b
 B Does the housing environment have high lethality and
   lack temporary protection?                                    1    c
 C Is temporary protection necessary and available?
                                                                 2    d
 D If safety is minimally adequate and safety planning is
   essential, mark No.

   If safety is present but uncertain in the future and
   safety planning is important, mark Yes.                       4    3

   Note: This assessment is related to the client's housing
   environment. It may include, but is not limited to, the
   presence of any domestic violence.




17 Parenting Skills (Individual)
   See note below                                               Yes   No
 A Does the household include children under the age of
   18?                                                           b    n/a
 B Are there safety concerns regarding parenting skills
   (see Note 1 below)?                                           1    c
 C Are the client's parenting skills well developed (parent
   is a positive role model, maintains child's
   structure/routine, and is involved in child's education)?
                                                                 5    d
 D Are the client's parenting skills adequate (parent
   usually employes age-appropriate parenting
   techniques)?                                                  4    e
 E Are the client's parenting skills apparent (parent
   makes some effort to apply age-appropriate parenting
   techniques, but application is inconsistent)?
                                                                 3     f
 F Are the client's parenting skills minimal (parent is
   generally disengaged, discipline consists primarily of
   yelling, blaming, shaming)?                                   2    1

   Note: State law requires that evidence of child abuse be
   reported immediately to the proper authorities.




18 Credit History (Individual)
                                                                Yes   No
 A Does the client have any outstanding judgements,
   evictions, bankruptcy, or forclosure?                         b    c
 B Has the client implemented a documented credit repair
   plan?                                                         2    1
 C Does the client have any debt in collections?
                                                                 d    e
 D Has the client implemented a documented credit repair
   plan?                                                         3    2
 E Has the client ever had credit (credit cards, loans,
   etc.)?                                                        f    3
 F Does the client have good credit with a manageable
   debt ratio?                                                   4    5
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