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Homeless Questionnaire January 25, 2012 Introduction: Only use this form for homeless people who WILL

L 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 doesnt 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 Over 10 years Over 20

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

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 13. Are you able to eat regularly? Yes 14. How often do you eat? Less than 1x/day 1x/day

No No 2x/day 3x/day

15. What caused you and/or your family to leave your last living arrangement? (Check all that apply) Child Abuse Couldnt 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 Yes No No Yes Yes No No HS Graduate GED

19. Have you ever felt discriminated against because you are homeless? 20. Since you have been homeless, have you experienced any violence? 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 No

More than 1 year ago Do not Recall

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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