HUD-5384 VAWA Emergency Transfer Data Collection Form

U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM

Note: The information in this form may be collected by way of email communication, DocuSign,
Microsoft Forms, or any other survey method collection. HUD may tailor this form to ask detailed
questions by selecting different areas of this form as is relevant to their program area. These questions
may also be embedded in existing checklists.
VAWA EMERGENCY TRANSFER DATA COLLECTION FORM
([INSERT RELEVANT HUD OFFICE])
BASIC INFORMATION:
Please provide information for the point of contact (POC) completing this form.
Name:
Email:
TYPE OF HOUSING PROVIDER: (Select all that apply.)
(Depending on which program is selected, program specific questions will be tailored to the response.)
a. Public Housing Authority
1. Public Housing Program
2. Housing Choice Voucher (HCV) Program (Including Project-based Vouchers (PBVs))
3. Moderate Rehabilitation Program
b. Multifamily Owner or Manager
c. Continuum of Care (CoC) Recipient
d. Emergency Solutions Grants (ESG) Recipient
e. Rural Housing Stability Assistance Recipient
f. HOPWA Grantee
g. HOME Participating Jurisdiction/Housing Trust Fund Grantee
BASIC INFORMATION – Public Housing Agency (PHA)
PHA Name:
PHA Code:
BASIC INFORMATION – Multifamily Housing (MFH)
Information related to the collection of Emergency Transfer Data will be provided by Owners/Managers
through form HUD-52670 as part of their monthly voucher.
BASIC INFORMATION – Continuum of Care (CoC)
CoC Number and Name:
Recipient/Subrecipient Name(s):
BASIC INFORMATION – Emergency Solutions Grants (ESG)
ESG Grantee:
Subrecipient Name(s):
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U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM

BASIC INFORMATION – Rural Housing Stability Assistance Program
Recipient:
Subrecipient Name(s):
BASIC INFORMATION – Housing Opportunities for Persons With AIDS (HOPWA)
Grantee:
Project Sponsor(s):
BASIC INFORMATION – HOME Investment Partnerships Program (HOME)/Housing Trust
Fund (HTF)
HOME Participating Jurisdiction:
HTF Grantee:
Section I: VAWA EMERGENCY TRANSFER PLANS
1. If you make your VAWA Emergency Transfer Plan publicly available on the internet, please
provide the URL/internet address here:
__________________________________________________________________________
2. If you do not make your VAWA Emergency Transfer Plan publicly available on the internet,
please submit a copy of your current VAWA Emergency Transfer Plan when you submit this
report to HUD.
3. If you do not make your VAWA Emergency Transfer Plan publicly available, please state
why it is infeasible to make it publicly available.
___________________________________________________________________________
In the sections below, please provide data for emergency transfers under VAWA. Please see the
Definitions section below for the definitions of the bolded and italicized terms.
Section II: TOTAL VAWA EMERGENCY TRANFER REQUESTS
4. Total Number of VAWA Emergency Transfer Requests
a. What is the total number of VAWA emergency transfer requests received during
the current [ANNUAL OR MONTHLY] reporting period of [INSERT
REPORTING TIME PERIOD]? _______
b. How many requests are pending review and pending approval placement from
prior [YEARS OR MONTHS]?_______
c. Add together 4a and 4b to get the TOTAL number of VAWA emergency transfer
requests for the reporting period of [INSERT REPORTING TIME PERIOD]. What
is the combined number? ______
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U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM

Section III: INCOMPLETE AND DENIED VAWA EMERGENCY TRANSFER REQUESTS
For the questions below, report on the status of the total number of VAWA emergency transfer requests
from the reporting period in Question 4c.
5. Incomplete VAWA Emergency Transfer Requests
a. How many VAWA emergency transfer requests for the reporting period (from 4c)
were incomplete?______
b. Identify the reasons the VAWA emergency transfer requests were incomplete and list
the total number of requests for each outcome:
i. Housing provider was not able to reach tenant for follow up. _____
ii. Housing provider’s VAWA Emergency Transfer Plan requires emergency
transfer requests be in writing and the tenant did not provide the request in
writing. _____
iii. The tenant did not complete and submit the VAWA Self-Certification Form or
provide other documentation of VAWA victim status after a written request from
the housing provider. _____
iv. Other ______
v. If “other”, please provide the reason(s) the VAWA emergency transfer requests
were incomplete:
________________________________________________________________
6. How many VAWA emergency transfer requests for the reporting period (from 4c) were
denied? _______
Section IV: APPROVED VAWA EMERGENCY TRANSFER REQUESTS
7. Number of Approved VAWA Emergency Transfer Requests
a. How many VAWA emergency transfer requests (from 4c) were approved that were
received during the current [ANNUAL OR MONTHLY] reporting time period of
[INSERT REPORTING TIME PERIOD]? _______
b. How many VAWA emergency transfer requests (from 4c) were approved that were
pending review from prior reporting periods? ______
c. How many VAWA emergency transfer requests (from 4c) were approved and
pending placement from prior reporting periods? ______
d. Add together 7a and 7b and 7c to get the TOTAL number of approved VAWA
emergency transfer requests for the reporting period of [INSERT REPORTING
TIME PERIOD]. What is the combined number? _____
8. For the questions below, report on the status of the total number of approved VAWA
emergency transfer requests for the reporting period (from 7d).
a. How many approved VAWA emergency transfer requests resulted in an internal
transfer to a safe unit? ______
b. How many approved VAWA emergency transfer requests resulted in an external
transfer to a safe unit? _____
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U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM

c. How many approved VAWA emergency transfer requests are pending
placement?_______
9. For approved VAWA emergency transfer requests (7d) that are pending placement, please
identify the reason the requests are pending placement and list the total number of requests
for each reason:
a. Awaiting placement for a safe unit ______
(This includes situations when the victim has a Housing Choice Voucher or other
tenant-based assistance and is searching for a safe unit.)
b. Awaiting placement for a unit that meets occupancy standards_____
c. Awaiting placement for a unit that victim/household meets program eligibility
requirements for _________
d. Awaiting a unit that meets the household’s accessibility needs _____
e. Awaiting issuance of a Housing Choice Voucher _____
f. Other _________
10. How many approved VAWA emergency transfer requests (from 7d) did not result in
completed VAWA emergency transfer requests and the victim is no longer seeking an
emergency transfer? _______
11. For approved VAWA emergency transfer requests that did not result in completed VAWA
emergency transfer requests and which the victim is no longer seeking a transfer (from 10),
please provide the total number of requests that failed to transfer for that reason:
a. Could not find a safe unit _____
b. Could not find an available unit _____
c. Could not find a unit that met occupancy standards _____
d. Could not find a unit that met the household’s accessibility needs _____
e. Victim/household’s program eligibility _____
f. No follow up from victim/household ______
g. Victim vacated unit ______
h. Victim withdrew the emergency transfer request and decided to remain in current
unit ______
i. Other ______
If “other”, please describe the reason for the failures to transfer:
_____________________________________________________________
_____________________________________________________________
Section V: TIMEFRAMES OF VAWA EMERGENCY TRANSFER REQUEST
12. How long did it take for VAWA emergency transfer requests to be approved, denied, or
determined to be incomplete after they were received (i.e. the time between when a request
was expressly made to when the housing provider finished its review and (1) approved the
request, (2) denied the request, or (3) determined that the request was incomplete)? List the
number of VAWA emergency transfer requests for each timeframe below.
a. 0-7 calendar days ________
b. 8-14 calendar days_______
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U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM
c.
d.
e.
f.

15-30 calendar days ______
31-90 calendar days ______
91-120 calendar days __________
More than 120 calendar days______

13. How long does it take for VAWA emergency transfer requests to be completed after they
were approved (i.e. the time between when a request was approved to when the tenant has
moved into a safe unit)? List the number of VAWA emergency transfer requests for each
timeframe below.
a.
b.
c.
d.
e.
f.

0-7 calendar days ______
8-14 calendar days______
15-30 calendar days ______
31-90 calendar days ______
91-120 calendar days ________
More than 120 calendar days ________

14. What was the TOTAL length of time for VAWA emergency transfer requests to be
completed after they were received (i.e. the time between when a request was expressly made
to a housing provider to when the tenant has moved into a safe unit)? Please provide the
number of VAWA emergency transfer requests for each timeframe below.
a.
b.
c.
d.
e.
f.

0-7 calendar days ______
8-14 calendar days______
15-30 calendar days ______
31-90 calendar days ______
91-120 calendar days ________
More than 120 calendar days _______

Section VI:
15. Please check each item below that applies to you or is provided under your VAWA
Emergency Transfer Plan:
[ ] We collaborate or coordinate with public housing authorities, Continuums of Care,
owners/managers, consortiums, or other providers for purposes of providing housing
and services for victims.
[ ] We offer interim housing for VAWA victims waiting for emergency transfers.
[ ] We provide a waitlist preference for victims of domestic violence, sexual assault,
dating violence, and stalking.
[ ] We have a VAWA service coordinator or someone who functions as a VAWA service
coordinator.

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U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM

[ ] We conduct outreach activities to organizations that assist or provide resources to
VAWA victims.
VAWA EMERGENCY TRANSFERS – SUB-QUESTIONS:
16. PHAs with a Stability Voucher (SV) Program
a. How many SVs were used to respond to a VAWA emergency transfer request? _____
b. How many of those SVs resulted in a completed VAWA emergency transfer request?
_____
Definitions
Approved: An emergency transfer request is approved if the housing provider has finished its review of
the emergency transfer request and has determined that the tenant is eligible for an emergency transfer
under VAWA.
Completed: An emergency transfer request is completed when the victim has successfully been
transferred to a safe unit.
Denied: An emergency transfer request is denied if the housing provider has finished its review of the
transfer request and has determined that the tenant is ineligible for an emergency transfer request under
VAWA (i.e. the incident or request is not covered under VAWA).
External Transfer: An external transfer refers to an emergency relocation of a tenant to another unit
where the tenant would be categorized as a new applicant; that is, the tenant must undergo an application
process in order to reside in the new unit.
Incomplete: An emergency transfer request is incomplete if the housing provider could not complete its
review of the transfer request because the tenant did not submit necessary documentation or follow up to
enable the housing provider’s review.
Internal Transfer: An internal transfer refers to an emergency relocation of a tenant to another unit
where the tenant would not be categorized as a new applicant; that is, the tenant may reside in the new
unit without having to undergo an application process.
Pending Placement: An emergency transfer request is pending placement if the housing provider has
approved the emergency transfer request and the victim is waiting for permanent placement into a safe
unit. This includes situations where a victim has a Housing Choice Voucher or other tenant-based
assistance and is searching for a safe unit.
Pending Review: An emergency transfer request is pending review when the request has been expressly
made and the housing provider is reviewing the request to determine whether a tenant is eligible for a
VAWA emergency transfer request.
Received: An emergency transfer request is received when it is first expressly made to the housing
provider for review. This includes if the request is made verbally, even if the housing provider’s VAWA
Emergency Transfer Plan requires requests be made in writing.
Safe Unit: A safe unit is a housing unit that the victim believes is safe.

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U.S. Department Of Housing And Urban Development
OMB Approval No. XXXX-XXX
Exp. XXXX

VAWA EMERGENCY TRANSFER DATA
COLLECTION FORM

Public Reporting Burden for this collection of information is estimated to average 30 minutes to 60
minutes per response. This includes the time for collecting, reviewing, and reporting. Comments
concerning the accuracy of this burden estimate and any suggestions for reducing this burden can be sent
to the Reports Management Officer, QDAM, Department of Housing and Urban Development, 451 7th
Street, SW, Washington, DC 20410. A Federal agency may not collect this information, and you are not
required to complete this form, unless it displays a currently valid Office of Management and Budget
control number.

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