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2019 Point in Time Count (Observed)

  1. 2018 Refusal/Observation Tool

    (Only complete if you cannot complete an interview questionnaire and complete one for each household)

  2. Survey Collected From*

  3. If blank enter the word "BLANK"

  4. Please indicate why you are using the observation tool?*

  5. 1. Total persons staying together as household: (Use separate observation forms for each household)

  6. Example: northwest corner of 1st Ave and Main Street

  7. 4. Is this person homeless: How certain are you that the person meets HUD’s criteria of staying in a place not meant for human habitation (e.g., tent, vehicle, park, bench, etc.)?*

  8. 5. What is your estimate of this persons age?*

  9. 6. How do you define your gender? *

  10. 7. Ethnicity*

  11. 8. Race *

    (check all that apply):

  12. 9.1 Self

  13. 9.2b Gender*

  14. 9.2c Race (Check All that Apply):*

  15. 9.2e Ethnicity*

  16. 9.2f Veteran Status*

  17. 9.2g Disability*

  18. 9.3b Gender*

  19. 9.3c Race (Check All that Apply):*

  20. 9.3e Ethnicity*

  21. 9.3f Veteran Status*

  22. 9.3g Disability*

  23. 9.4b Gender*

  24. 9.4c Race (Check All that Apply):*

  25. 9.4e Ethnicity*

  26. 9.4f Veteran Status*

  27. 9.4g Disability*

  28. 9.5b Gender*

  29. 9.5c Race (Check All that Apply):*

  30. 9.5e Ethnicity*

  31. 9.5f Veteran Status*

  32. 9.5g Disability*

  33. 9.6b Gender*

  34. 9.6c Race (Check All that Apply):*

  35. 9.6e Ethnicity*

  36. 9.6f Veteran Status*

  37. 9.6g Disability*

  38. 9.7b Gender*

  39. 9.7c Race (Check All that Apply):*

  40. 9.7e Ethnicity*

  41. 9.7f Veteran Status*

  42. 9.7g Disability*

  43. 9.8b Gender*

  44. 9.8c Race (Check All that Apply):*

  45. 9.8e Ethnicity*

  46. 9.8f Veteran Status*

  47. 9.8g Disability*

  48. 9.9b Gender*

  49. 9.9c Race (Check All that Apply):*

  50. 9.9e Ethnicity*

  51. 9.9f Veteran Status*

  52. 9.9g Disability*

  53. Leave This Blank: