Page 65

DEO LIHEAP Policies and Procedures Manual Page 65

EXHIBIT 4 LIHEAP Performance Measures Data Collection Worksheet

PART 1 - CLIENT INFORMATION Complete the following information based on the Applicant’s LIHEAP Application Applicant Name Customer of Record (if not Applicant) Vendor (Electric) Account Number Vendor (Gas) Account Number

PART 2 - MAIN ENERGY SOURCE Check which source is used for each energy need ENERGY NEED ELECTRIC GAS OTHER - Describe HEATING COOLING OTHER (cooking, water, etc.)

PART 3 - IMMINENT RISK YES NO QUESTION Was the applicant considered to be at imminent risk of losing needed home energy source, and disruption was halted as a result of the applicant receiving a LIHEAP benefit, either Home Energy or Crisis (alone or in combination with another program)? • If Yes, count the Applicant as having home energy disruption halted as a result of LIHEAP assistance • If No, do NOT count the applicant as having home energy disruption halted as a result of LIHEAP assistance, however, the applicant may still be eligible for services

Some additional questions to consider if assistance is needed in determining if the Applicant should be counted in this category YES NO QUESTION Does the applicant have a shut-off notice? This does not include a late bill or late notice. Does the applicant have less than 7 days of pre-paid electricity usage or fuel? Is the applicant using an alternative source for heating or cooling, i.e., they are using a fan because the HVAC unit is operable but not running correctly?

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Page 65

Official source

DEO LIHEAP Policies and Procedures Manual Page 65

EXHIBIT 4 LIHEAP Performance Measures Data Collection Worksheet

PART 1 - CLIENT INFORMATION Complete the following information based on the Applicant’s LIHEAP Application Applicant Name Customer of Record (if not Applicant) Vendor (Electric) Account Number Vendor (Gas) Account Number

PART 2 - MAIN ENERGY SOURCE Check which source is used for each energy need ENERGY NEED ELECTRIC GAS OTHER - Describe HEATING COOLING OTHER (cooking, water, etc.)

PART 3 - IMMINENT RISK YES NO QUESTION Was the applicant considered to be at imminent risk of losing needed home energy source, and disruption was halted as a result of the applicant receiving a LIHEAP benefit, either Home Energy or Crisis (alone or in combination with another program)? • If Yes, count the Applicant as having home energy disruption halted as a result of LIHEAP assistance • If No, do NOT count the applicant as having home energy disruption halted as a result of LIHEAP assistance, however, the applicant may still be eligible for services

Some additional questions to consider if assistance is needed in determining if the Applicant should be counted in this category YES NO QUESTION Does the applicant have a shut-off notice? This does not include a late bill or late notice. Does the applicant have less than 7 days of pre-paid electricity usage or fuel? Is the applicant using an alternative source for heating or cooling, i.e., they are using a fan because the HVAC unit is operable but not running correctly?