Point-in-Time Count of Homeless Persons -- See instructions on back                                           January 2007
Victims of Domestic Violence - Only fill in gender and birth year for individuals 1-4 below

Individual #1

Gender:
	Male		Female

Birth Year:

Individual #2

Gender:
	Male		Female

Birth Year:

Individual #3

Gender:
	Male		Female

Birth Year:

Individual #4

Gender:
	Male		Female

Birth Year:

Disabilities (For each individual above, circle the related number if they have a disability)
1 2 3 4	Physical/medical (permanent)	1 2 3 4	Physical (temporary)
1 2 3 4	Mental Health	1 2 3 4	Alcohol or drug abuse
1 2 3 4	Visual (Uncorrected)	1 2 3 4	Developmental
1 2 3 4	HIV/AIDS	1 2 3 4	Literacy
1 2 3 4	Untreated dental	1 2 3 4	Other:_________

Have anyone in your household ever served in the Armed Forces of the US?
	No		Yes
Is anyone in your household receiving Veterans Administration benefits?
	No		Yes

Household Information (Applies to everyone listed above)

Where did you stay last night (check one)?
	Emergency Shelter		Transitional housing
	Temporarily living with family or friends		Out of doors (Street, tent)
	Vehicle		Abandoned building
	Jail
What month and year did you become homeless? Month ________ / Year_________ How many times have you become homeless over the past three years?_________

What situations have caused you to become homeless    (check all that apply)
	Victim of domestic violence	Evicted for non-payment
	Job lost	Evicted for other reasons
	Medical costs	Unable to pay rent/mortgage
	Convicted of a felony	Convicted of a misdemeanor
	Poor credit rating	Family break-up
	Mental Illness	Failed job drug screening
	Medical problems	Temporary living situation ended
	Alcohol or drug use	Discharged from an institution or jail
	Lack of child care	Lack of job skills
	Language Barrier	Other:_________

Source(s) of household income (check all that apply)
	None	Social Security
	Unemployment insurance	Part-time work
	Public assistance	Employed at low-wage job
	Relatives, partners or friends	Day laborer type jobs
	L&I/Workman's compensation	Farm or other migrant agricultural work
	Other __________

What is the zip code of the apartment, room, or house you last lived for six consecutive months or more? 

Zip code:______________
OR 
City name:____________

Thank you for completing this survey. Your response will help us improve services to homeless persons.

Instructions

At the very least, please fill in the gender and year born for each household member.  If you do not know the precise birth year of a household member, guesses are OK.

Do not provide initials, birth day, or birth month for victims of domestic violence or anyone you do not have written informed consent.

Purpose
The purpose of this survey is to assist with the planning of services for homeless individuals to identify the types of assistance needed. 

Who should complete this survey?
Any homeless person. "Homeless" means persons who, on one particular day or night, do not have a decent and safe shelter or sufficient funds to purchase a place to stay.  People living in emergency shelters and transitional shelters are considered homeless. People living temporarily with friends or family or "couch surfing" should complete this survey.

Anyone living in on of the situations listed in the the "Current Living Status" question should complete the survey.

People living in a dwelling lacking any of the following should be considered homeless (check "living out of doors"): ability to cook hot food, drinking water, restroom,  heat, or ability to bath.

Identifying Information
Please do not provide your name, social security number, or anything that identifies you by name.

Individual Information
Space is provided to collect unique identifying information (initials, gender, and birthday) and some basic information for four individuals.  If there are more than four members in your household, staple a second form to the first and enter the client information on the second form.

Household Information
The information collected in the "Household Information" section applies to all the members of the household listed in the "Individuals" blanks.  A single person is considered a household (i.e., "a household consisting of one person"), so single individuals should fill-in the household section.

What if I don't know, or are unwilling to provide an answer to a question?
No part of this survey is required.  If you do not know an answer, or are uncomfortable providing an answer, you can leave the question blank.  

At the very least, please fill in the gender and birth year for each household member.  If you do not know the precise birth year of a household member, guesses are OK.

Additional Questions About Survey
If you have any questions about how to fill-out this survey, or how this information will be used, please don't hesitate to call (360) 725-2930.

Thank you for helping us improve services to homeless persons.