City of Interview

County

Interviewer

Estimate the age range

Where are you sleeping tonight, Thursday, January 29th?

Where are you sleeping tonight, Thursday, January 29th?

Rapid Re-Housing program details

Please define Transitional Housing Program from above question.

Rapid Re-Hosuing program other

Please define Other Shelter from above question.

Permanent Housing program deatils

Permanent Housing program other

Why did you choose to complete an observation summary?

Please define Other Reason for Observational Summary from above question.

Have you ever met this person?

What is their gender? (This is the gender that you observe.)

Other Gender

What is their race? Check all the answers that you observe.

Please list any other unique identifiers that you observe (companion animals, other household members.

Emergency Shelter detail

Emergency Shelter other

Transitional Housing program detail

Transitional Housing program other

Were you homeless immediately before entering treatment facility or shelter?

What are the first three letters of your first name?

What are the first three letters of your last name?

Birth Year

Birth Month

Birth Day

What gender do you identify as?

Other Gender

What is your race?

Is anyone staying with you tonight?

Who is staying with you?

If you are homeless now, how long has this current episode lasted?

How many times have you lived on the street or in an emergency shelter in the past 3 years?

In the past three years have you spent 12 months or more homeless?

Have you been diagnosed with any of the following conditions? (note: Receiving disability not required)

• Mental Illness
• Alcohol Use Disorder
• Substance Use Disorder
• HIV/AIDS

Are you living with any condition that significantly limits your ability to care for yourself, perform manual tasks, see, hear, eat, sleep, walk, stand, bend, speak, breathe, think, communicate, or work?

Have you ever served in the US Army, Navy, Air Force, Marine Corps, or Coast Guard?

Were you called to active duty as a member of the National Guard or as a Reservist?

Are you a currently fleeing domestic violence, dating violence, sexual assault, or stalking?

Are you living with a chronic health condition? (select all that apply)

Other chronic health conditions:

How do you get your medical needs met?

Medical needs met other:

When did you have your last physical?

Which vaccine did you receive?

Are you interested in getting vaccinated?

Were you homeless before entering any of theses facilities?

What are the first three letters of your first name?

What are the first three letters of your last name?

Birth Year

Birth Month

Birth Day

What gender do you identify as?

What is your race?

Can you tell me all the places that you slept in the past week?(Select all that apply)

Please define Other Location from above question.

How many times have you lived on the street or in an emergency shelter in the past 3 years?

Do the times above add up to 12 or more months?

In order to stay in any housing situation, have you done any of the folowing?(Choose all that apply)

Who did you live with the last time you livced in secure/stable housing?

Please define Other Secure/Stable Housing from above question.

Do you need help with any of the folowing?(Check all that apply)

Please define Other Needs from above question.

Are you currently fleeing domestic violence, dating violence, sexual assault or stalking?

Are you experiencing any health conditions?(Select all that apply)

Please define Other Health Conditions from above question.

If you have access to medical care, how do you get your medical needs met?(Select all that apply)

Please define Other Medical Centers Used from above question.

When did you have your last healthcare physical?

Notes: