2012 Homeless Questionnaire

Homeless Questionnaire – January 25, 2012 Introduction: Only use this form for homeless people who WILL NOT be staying at a shelter tonight. Develop an introduction that you are comfortable with, but make certain that you convey the following information: All personal information collected on this form will remain strictly confidential. All bolded questions must be completed, otherwise the data is not useable. 1. Would you mind answering a few questions? If doesn’t want to participate, please fill out Seen but not Surveyed form. 2. Have you been involved this week in a homeless count or interview process? □ Yes □ No 3.

Are you currently homeless? □ Yes

□ No

4. Length of current episode of homelessness. □Under 1 year □ 1-3 years □ 3-5 years □Over 5 years years

□Over 10 years

□Over 20

5. Have you experienced at least four episodes of homelessness in the past three years? □ Yes □ No 6. Where will you be sleeping tonight, January 25th, 2012? (Check only one) □ Street □ Vehicle □ In a Camp □ In a Park □ Motel/Hotel □ Temporarily with Family/ Friend □ Other__________________________________ 7. Household Type: (Check only one) □ Single adult □ Couple without children □ Single parent w/children □ Two parent with children □ Unaccompanied youth (17 or under) □ Unaccompanied pregnant youth (17 or under) 8. Please fill out for each family member Gender □M □F □M □F Age First 1 letter First Name First 3 letters of Last Name

□M □F

□M □F

□M □F

□M □F

9. Veteran (18+ years old and US Armed Service or Activated National Guard/Reservist) □ Yes □ No 10. Do you have any of the following disabling conditions? □ Mental or Emotional Disorder □ Physical Disability □ Developmental Disability □ Chronic Substance Abuse □ No Disabling Condition 11. What do you do for income/money? __________________________________________________

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12. Are you looking for a job? □ Yes

□ No

13. Are you able to eat regularly? □ Yes

□ No

14. How often do you eat? □ Less than 1x/day

□ 1x/day

□ 2x/day

□ 3x/day

15. What caused you and/or your family to leave your last living arrangement? (Check all that apply) □ Child Abuse □ Couldn’t afford rent □ Credit □ Criminal History □ Domestic Violence □ Drugs/Alcohol at home □ Drug/Alcohol (self) □ Evicted by landlord □ Gambling □ Kicked out by family/friend □ Medical problem □ Mental or Emotional Disorder □ Poor Rental History □ Pregnancy □ Runaway □ Unemployed □ Foreclosure □ Other________________________________________ 16. How far did you go in school? □ Still in HS or MS □ Grade 1-9 □ Grade 10-12 □ Some College □ College Graduate 17. Have you ever been in jail? 18. Have you ever been in prison?

□ Yes

□ HS Graduate

□ GED

□ No

□ Yes

□ No

19. Have you ever felt discriminated against because you are homeless?

□ Yes

□ No

20. Since you have been homeless, have you experienced any violence?

□ Yes

□ No

21. Do you have any medical problems?

□ Yes

□ No

22. When was the last time you saw a doctor? □ Past Year □ 2-3 years ago □ 4-5 years ago □ Over 5 years ago 23. Do you have any dental problems? □ Yes

□ More than 1 year ago □ Do not Recall

□ No

24. When was the last time you saw a dentist? □ Past Year □ 2-3 years ago □ 4-5 years ago □ Over 5 years ago

□ More than 1 year ago □ Do not Recall

25. What is the hardest part about being homeless? ___________________________________________________________________________________ ___________________________________________________________________________________ __ 26. What can be done to improve your current situation? _____________________________________ ___________________________________________________________________________________ _

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