Household Member

Point-in-Time Count of Homeless Persons -- See instructions on back January 2006
Victims of Domestic Violence - Only fill in gender and birth year for individuals 1-4 below

Individual #1

First Initial:

Middle Initial:

Last Initial:

Gender:
	Male		Female

Birth Month:

Birth Day:

Birth Year:

Individual #2

First Initial:

Middle Initial:

Last Initial:

Gender:
	Male		Female

Birth Month:

Birth Day:

Birth Year:

Individual #3

First Initial:

Middle Initial:

Last Initial:

Gender:
	Male		Female

Birth Month:

Birth Day:

Birth Year:

Individual #4

First Initial:

Middle Initial:

Last Initial:

Gender:
	Male		Female

Birth Month:

Birth Day:

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 drugs 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

Number of other individuals in household (in addition to those above): _______

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	"Couch Surfing"
	Out of doors (Street, tent)	Vehicle
What month and year did you become homeless? Month ________ / Year_________ How many times have you become homeless over the past three years? _________

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.

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 without any of the following should be considered homeless: ability to cook hot food, drinking water, restroom, or heat.

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 one individual. There is an additional three spaces to enter basic information for other household members. If there are more than four members in your household, enter the number of additional members in the blank next to the "Number of other individuals in household" question.

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 year born 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.