“I’m going to ask you some general survey questions. Let’s begin!” Head of Household/ P1 Person 2 Person 3 Person 4 Person 5 What are your… Initials? Date of Birth? Age? Head of Household Person 2 Person 3 Person 4 Person 5 How are Person 2 to 5 related to you? [This question is only for the Head of Household] ⃝ Head of Household ⃝ Child ⃝ Spouse or Partner ⃝ Other Family Member ⃝ Other, non-related ⃝ ⃝ Spouse or Partner ⃝ Other Family Member ⃝ Other, non-related ⃝ Child ⃝ Spouse or Partner ⃝ Other Family Member ⃝ Other, non-related ⃝ ⃝ Spouse or Partner ⃝ Other Family Member ⃝ Other, non-related Head of Household Person 2 Person 3 Person 4 Person 5 What is your primary race? [Please select one] ⃝ American Indian or Alaskan Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ White ⃝ Doesn’t Know ⃝ Refused ⃝ ⃝ American Indian or Alaskan Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ ⃝ Doesn’t Know ⃝ Refused ⃝ Other: ⃝ American Indian or Alaskan Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ White ⃝ Doesn’t Know ⃝ Refused ⃝ Other: ⃝ American Indian or Alaskan Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ ⃝ Doesn’t Know ⃝ Refused ⃝ ⃝ American Indian or Alaskan Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ White ⃝ Doesn’t Know ⃝ Refused ⃝ Other:
Head of Household Person 2 Person 3 Person 4 Person 5 Are you Hispanic or Latino? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Which gender identity do you most identify with? ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Female to Male ⃝ Gender Non- Conforming ⃝ Non-Binary ⃝ Doesn’t Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Non-Binary ⃝ Doesn’t Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Non-Binary ⃝ Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Non-Binary ⃝ Doesn’t Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Non-Binary ⃝ Doesn’t Know ⃝ Refused Which of the following best represents how you think of yourself? ⃝ Lesbian or Gay ⃝ Straight ⃝ Bisexual ⃝ Something Else ⃝ Doesn’t Know ⃝ Refused ⃝ Lesbian or Gay ⃝ Straight ⃝ Bisexual ⃝ Something Else ⃝ Doesn’t Know ⃝ Refused ⃝ Lesbian or Gay ⃝ Straight ⃝ Bisexual ⃝ Something Else ⃝ Doesn’t Know ⃝ Refused ⃝ Lesbian or Gay ⃝ Straight ⃝ Bisexual ⃝ Something Else ⃝ Doesn’t Know ⃝ Refused ⃝ Lesbian or Gay ⃝ Straight ⃝ Bisexual ⃝ Something Else ⃝ Doesn’t Know ⃝ Refused Are you currently experiencing an abusive relationship? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Are you currently employed or ⃝ Currently Employed ⃝ Attending School ⃝ Currently Employed ⃝ Attending School ⃝ Currently Employed ⃝ Attending School ⃝ Currently Employed ⃝ Attending School ⃝ Currently Employed ⃝ Attending School
attending school? ⃝ Both ⃝ Neither ⃝ Doesn’t Know ⃝ Refused ⃝ Both ⃝ Neither ⃝ Doesn’t Know ⃝ Refused ⃝ Both ⃝ Neither ⃝ Doesn’t Know ⃝ Refused ⃝ Both ⃝ Neither ⃝ Doesn’t Know ⃝ Refused ⃝ Both ⃝ Neither ⃝ Doesn’t Know ⃝ Refused How long ago were you last employed or attending school? ⃝ Currently Employed/ in school ⃝ Less than 1 Month ⃝ 1-6 Months ⃝ 6-12 Months ⃝ 1-2 Years ⃝ 2-5 Years ⃝ 5+ Years ⃝ Employed ⃝ Doesn’t Know ⃝ Refused ⃝ Currently Employed/ in school ⃝ Less than 1 Month ⃝ 1-6 Months ⃝ 6-12 Months ⃝ 1-2 Years ⃝ 2-5 Years ⃝ 5+ Years ⃝ Never Employed ⃝ Doesn’t Know ⃝ Refused ⃝ Currently Employed/ in school ⃝ Less than 1 Month ⃝ 1-6 Months ⃝ 6-12 Months ⃝ 1-2 Years ⃝ 2-5 Years ⃝ 5+ Years ⃝ Never Employed ⃝ Doesn’t Know ⃝ Refused ⃝ Currently Employed/ in school ⃝ Less than 1 Month ⃝ 1-6 Months ⃝ 6-12 Months ⃝ 1-2 Years ⃝ 2-5 Years ⃝ 5+ Years ⃝ Never Employed ⃝ Doesn’t Know ⃝ Refused ⃝ Currently Employed/ in school ⃝ Less than 1 Month ⃝ 1-6 Months ⃝ 6-12 Months ⃝ 1-2 Years ⃝ 2-5 Years ⃝ 5+ Years ⃝ Never Employed ⃝ Doesn’t Know ⃝ Refused “Now I’m going to ask you some questions about your physical, mental, and sexual health.” Head of Household Person 2 Person 3 Person 4 Person 5
Do you have any mental health issues? [E.g. chronic depression, bipolar disorder, or schizophrenia] ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you feel you have an impairment caused by alcohol use? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you feel you have an impairment caused by drug abuse? This includes prescription drugs if used differently than prescribed. ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Just so I understand what you told me previously, do you have a disability? ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [Skip to Q24} ⃝ Doesn’t Know ⃝ Refused Do you expect this disability to be long term or permanent? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Does this disability impair your ability to live independently? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused “We have two additional questions to see if you have experienced…” Head of Household Person 2 Person 3 Person 4 Person 5
Have you ever been in jail, prison, or juvenile hall? ⃝ Jail ⃝ Prison ⃝ Juvenile Hall ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Jail ⃝ Prison ⃝ Juvenile Hall ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Jail ⃝ Prison ⃝ Juvenile Hall ⃝ No ⃝ Know ⃝ Refused ⃝ Jail ⃝ Prison ⃝ Juvenile Hall ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Jail ⃝ Prison ⃝ Juvenile Hall ⃝ No ⃝ Doesn’t Know ⃝ Refused Have you ever served on active duty in the US forces? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused “I’m going to ask you some specific questions about your housing history and services you are accessing. Please try to give me your best estimates.” Head of Household Person 2 Person 3 Person 4 Person 5 When did you become homeless this time? [Ask for a specific date or round to nearest month] ⃝ Doesn’t know ⃝ Refused ⃝ Doesn’t know ⃝ Refused ⃝ Doesn’t know ⃝ Refused ⃝ Doesn’t know ⃝ Refused ⃝ know ⃝ Refused How many times have you been homeless in the past three years? [This only includes streets, emergency shelters, or safe havens] ⃝ 1 [only time] ⃝ 2 ⃝ 3 ⃝ 4 or more ⃝ Doesn’t know ⃝ Refused ⃝ 1 [only time] ⃝ 2 ⃝ 3 ⃝ 4 or more ⃝ Doesn’t know ⃝ Refused ⃝ 1 [only time] ⃝ 2 ⃝ 3 ⃝ 4 or more ⃝ Doesn’t know ⃝ Refused ⃝ 1 [only time] ⃝ 2 ⃝ 3 ⃝ 4 or more ⃝ know ⃝ Refused ⃝ 1 [only time] ⃝ 2 ⃝ 3 ⃝ 4 or more ⃝ know ⃝ Refused
Are you currently accessing any of the following services in the community? [Mark all that apply] Emergency Shelter Bus Passes Transitional Housing Mental Health Alcohol/Drug Counseling Employment Drop-in/Day Shelter Free Meals Legal Assistance Immigration Health Services Other: ⃝ Not Using Services ⃝ Doesn’t Know ⃝ Refused Emergency Shelter Bus Passes Transitional Housing Mental Health Alcohol/Drug Counseling Employment Drop-in/Day Shelter Free Legal Assistance Immigration Health Services Other: ⃝ Not Using Services ⃝ Doesn’t Know ⃝ Refused Emergency Shelter Bus Passes Transitional Housing Mental Health Alcohol/Drug Counseling Employment Drop-in/Day Shelter Free Meals Legal Assistance Immigration Health Services Other: ⃝ Not Using Services ⃝ Know ⃝ Refused Emergency Shelter Bus Passes Transitional Housing Mental Health Alcohol/Drug Counseling Employment Drop-in/Day Shelter Free Meals Legal Assistance Immigration Health Services Other: ⃝ Not Using Services ⃝ Know ⃝ Refused Emergency Shelter Bus Passes Transitional Housing Mental Health Alcohol/Drug Counseling Employment Drop-in/Day Shelter Free Meals Legal Assistance Immigration Health Services Other: ⃝ Not Using Services ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 What services would assist you in securing stable housing? [Mark all that apply] Rental Subsidy Legal Assistance Deposit Money Utility Costs Employment services Family Support Help Other: ⃝ Doesn’t Know ⃝ Refused Rental Subsidy Legal Assistance Deposit Money Utility Costs Employment services Family Support Help ⃝ Doesn’t Know ⃝ Refused Rental Subsidy Legal Assistance Deposit Utility Costs Employment services Family Support Help Other: ⃝ Doesn’t Know ⃝ Refused Rental Subsidy Legal Assistance Deposit Money Utility Costs Employment services Family Support Help Other: ⃝ Doesn’t Know ⃝ Refused Rental Subsidy Assistance Deposit Money Utility Costs Employment services Family Support Help ⃝ Doesn’t Know ⃝ Refused Thank you for taking the survey! [Subway cards should ONLY be given to those that are interviewed in person.]