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2019 Point in Time Count

  1. Survey Collected From*

  2. If blank entered please type "BLANK"

  3. If no location entered please type "BLANK"

  4. Are you experiencing homelessness?*

  5. 2. Did you already complete this survey this week?*

  6. If blank entered please type "BLANK"

  7. If blank entered please type "BLANK" ENTER IN ALL CAPS

  8. If blank entered please type "BLANK" ENTER IN ALL CAPS

  9. Entry Format MM/YYYY. If blank then 00/0000

  10. 8. Have you been living in an emergency shelter and/or on the streets for the past year or more?*

  11. 8a. If not, How many different times have you had to stay in a shelter or lived on the streets in the past three years?*

  12. 8b. How long would you say that you've stayed in these places added up the past 3 years?*

  13. 9. Do you have a physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury?*

  14. 9a. If yes, is this disability or condition expected to be of long-continuing or of indefinite duration?*

  15. 9b. Does it substantially impedes your ability to live independently?*

  16. 10. Check all that apply:*

  17. 11. Have you served in the U.S. Armed Forces?*

  18. 11a. May we have your name & number/location?*

  19. 12. Were you activated, into active duty, National Guard or reservist? *

  20. 13. How do you define your gender? *

  21. 14. Ethnicity*

  22. 15. Race (check all that apply):*

  23. 16. Which of the following best describes your family/household?*

  24. 17.1 Self

  25. 17.2b Gender*

  26. 17.2c Race (Check All that Apply):*

  27. 17.2e Ethnicity*

  28. 17.2f Veteran Status*

  29. 17.2g Disability*

  30. 17.3b Gender*

  31. 17.3c Race (Check All that Apply):*

  32. 17.3e Ethnicity*

  33. 17.3f Veteran Status*

  34. 17.3g Disability*

  35. 17.4b Gender*

  36. 17.4c Race (Check All that Apply):*

  37. 17.4e Ethnicity*

  38. 17.4f Veteran Status*

  39. 17.4g Disability*

  40. 17.5b Gender*

  41. 17.5c Race (Check All that Apply):*

  42. 17.5e Ethnicity*

  43. 17.5f Veteran Status*

  44. 17.5g Disability*

  45. 17.6b Gender*

  46. 17.6c Race (Check All that Apply):*

  47. 17.6e Ethnicity*

  48. 17.6f Veteran Status*

  49. 17.6g Disability*

  50. 17.7b Gender*

  51. 17.7c Race (Check All that Apply):*

  52. 17.7e Ethnicity*

  53. 17.7f Veteran Status*

  54. 17.7g Disability*

  55. 17.8b Gender*

  56. 17.8c Race (Check All that Apply):*

  57. 17.8e Ethnicity*

  58. 17.8f Veteran Status*

  59. 17.8g Disability*

  60. 17.9b Gender*

  61. 17.9c Race (Check All that Apply):*

  62. 17.9e Ethnicity*

  63. 17.9f Veteran Status*

  64. 17.9g Disability*

  65. 18. Are you currently homeless because of fleeing Domestic Violence, Dating Violence, Sexual Assault, or Stalking? *

  66. 19. Do you receive any type of income/benefits? *

  67. Choose all appropriate

  68. 20. Please check all of the reasons you became homeless: (Check all that apply)*

  69. 21. In what City/County did you live in when you first became homeless? *

  70. 22. In the past, have you ever been in? (Check all that apply)*

  71. 23. In the past year, what issues have you encountered in trying to get help or access services? (check all that apply)*

  72. 24. Think about the last time you felt that you were living in a safe and stable housing, how long ago was that?*

  73. 25. what is the primary reason you left or lost your last stable housing situation?*

  74. 26. In order to stay in any housing situation, have you ever…?*

    (Select all that apply)

  75. 27. What is the highest grade or level of schooling you completed?*

  76. Leave This Blank: