Geocode: 63210 San Diego 501 Interview Date: Subway Card # given: [Text written like this should NOT be read out loud and is only intended as support instruction for you] [Please fill in the bubbles by writing an X or filling it in] ⃝ ⃝ Hello, my name is ___________ and I’m conducting a survey to better understand housing situations and help provide better services. Can I ask you two quick questions? ⃝ Yes [Continue survey] ⃝ No [STOP survey and thank respondent] Where did you sleep last Thursday night/Friday morning (Jan 25th/26th)? ⃝ Street or sidewalk ⃝ Vehicle (car, van, RV, truck) ⃝ Tent/Hand-built structure ⃝ Park, beach or riverbed ⃝ Abandoned building ⃝ Bus, transit station, airport ⃝ bridge/overpass ⃝ Woods or outdoor encampment ⃝ Other location: [specify] ⃝ Emergency shelter ⃝ Transitional housing ⃝ Motel/Hotel ⃝ House or apartment ⃝ Jail, hospital, treatment program ⃝ Safe Haven ⃝ Couch surfing ⃝ Any other housing [STOP survey and thank respondent for their time] Has another volunteer asked you these same questions about where you were staying last Thursday night? ⃝ Yes [STOP survey and thank respondent for their time] ⃝ No ⃝ Know/Refused Would you like to take a 20 minute survey? You will get a $10 Subway gift card for your time. You can refuse to answer any question or end the survey at any time. Your answers are confidential and will only be used to improve the quality of our services. Would you like to continue? ⃝ Yes [Continue survey] ⃝ No [STOP survey and respondent for their time] Including yourself, how many adults or children in your household slept in the same location with you last Thursday night? Adults Children (Over 18) (Under 18) [Individuals who slept with other adults and/or children in the same location are considered a household. If other household individuals are present, use one survey form but interview each individual separately. If other household individuals are not present, ask if they will answer for them.]
“I’m going to ask you some general questions. Let’s begin!” Head of Household 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 persons 2 through 5 related to you? [This question is only for the Head of Household] ⃝ Head of Household ⃝ Child ⃝ Spouse or Partner ⃝ Family Member ⃝ Other, non-related ⃝ Child ⃝ Spouse or Partner ⃝ Other Family Member ⃝ Other, non-related ⃝ ⃝ Spouse or Partner ⃝ Family Member ⃝ Other, non-related ⃝ Child ⃝ Spouse or Partner ⃝ 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 ⃝ White ⃝ 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 ⃝ White ⃝ Doesn’t Know ⃝ Refused ⃝ Other: ⃝ American Indian or Alaskan Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ White ⃝ 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 ⃝ 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 Which gender do you most identify with? ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Doesn’t Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Female to Male ⃝ Gender Non- Conforming ⃝ Doesn’t Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Doesn’t Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Know ⃝ Refused ⃝ Male ⃝ Female ⃝ Trans Male to Female ⃝ Trans Female to Male ⃝ Gender Non- Conforming ⃝ Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Are you currently experiencing domestic violence? ⃝ 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 Head of Household Person 2 Person 3 Person 4 Person 5 Do you receive any Social Security Income? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Are you currently ⃝ Currently Employed ⃝ Currently Employed ⃝ Currently Employed ⃝ Currently Employed ⃝ Currently Employed
Of the following options, what do you think is the main reason for your homelessness? [Read the list out loud and have them select the primary reason they are homeless] ⃝ Loss of Job ⃝ Money Issues ⃝ Cost of Housing ⃝ Loss of family member ⃝ Disability ⃝ Alcohol/Drugs ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Cost of Housing ⃝ Loss of family member ⃝ Disability ⃝ Alcohol/Drugs ⃝ ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Cost of Housing ⃝ Loss of family member ⃝ Disability ⃝ Alcohol/Drugs ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Issues ⃝ Cost of Housing ⃝ Loss of family member ⃝ Disability ⃝ Alcohol/Drugs ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Loss of Job ⃝ Money Issues ⃝ Cost of Housing ⃝ Loss of family member ⃝ Disability ⃝ Alcohol/Drugs ⃝ Abuse/Violence ⃝ Kicked Out/Ran Away ⃝ Aged Out of Foster Care ⃝ Time in Jail/Prison ⃝ Divorce ⃝ Other: ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Did you become homeless in San County? ⃝ 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 “I’m going to ask you some questions about seeking housing services.” Head of Household Person 2 Person 3 Person 4 Person 5
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 Assistance Immigration Health Services ⃝ 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 ⃝ Doesn’t Know ⃝ Refused Emergency Shelter Bus Passes Transitional Housing Mental Health Alcohol/Drug Counseling Employment Drop-in/Day Shelter Free Meals Assistance Immigration Health Services Other: ⃝ Not Services ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 What services assist you in securing stable housing? [Mark all that Rental Subsidy Legal Assistance Deposit Money Utility Costs Employment services Family Support Help Other: ⃝ Know ⃝ Refused 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 Other: ⃝ Know ⃝ Refused 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 Other: ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Of the following options, can you tell me the number one reason that is preventing you from staying in a shelter? ⃝ Shelter Restrictions ⃝ Have family/friends or pet on the street ⃝ Safety concerns ⃝ Addiction to Alcohol/Drugs ⃝ Shelter Restrictions ⃝ Have family/friends or pet on the street ⃝ Safety concerns ⃝ Addiction to Alcohol/Drugs ⃝ Shelter Restrictions ⃝ Have family/friends or pet on the street ⃝ Safety concerns ⃝ Addiction to Alcohol/Drugs ⃝ Shelter Restrictions ⃝ Have family/friends or pet on the street ⃝ Safety concerns ⃝ Addiction to Alcohol/Drugs ⃝ Shelter Restrictions ⃝ Have family/friends or pet on the street ⃝ Safety concerns ⃝ Addiction to Alcohol/Drugs
[Read the list out loud and have them select the primary reason] ⃝ Waitlisted ⃝ Lack of transportation ⃝ Other: ⃝ Know ⃝ Refused ⃝ Waitlisted ⃝ Lack of transportation ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Waitlisted ⃝ Lack of transportation ⃝ Other: ⃝ Doesn’t Know ⃝ Refused ⃝ Waitlisted ⃝ Lack of transportation ⃝ Other: ⃝ Know ⃝ Refused ⃝ Waitlisted ⃝ Lack of transportation ⃝ Other: ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Do you need help to reconnect with family/friends or any support system? ⃝ 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 Head of Household Person 2 Person 3 Person 4 Person 5 If permanent housing was available, would you accept it? ⃝ 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 [Continue to next page] “I’m going to ask you questions about serving in the military.” Head of Household Person 2 Person 3 Person 4 Person 5
Head of Household Person 2 Person 3 Person 4 Person 5 What year did you enter active military service? ⃝ Doesn’t Know ⃝ Refused ⃝ Doesn’t Know ⃝ Refused ⃝ Doesn’t Know ⃝ Refused ⃝ Doesn’t Know ⃝ Refused ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 What year were you discharged from active military service? ⃝ Doesn’t Know ⃝ Refused ⃝ Doesn’t Know ⃝ Refused ⃝ Doesn’t Know ⃝ Refused ⃝ Know ⃝ Refused ⃝ Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 What was your discharge status? [Please select one] ⃝ Honorable ⃝ General honorable conditions ⃝ other than honorable conditions ⃝ Dishonorable ⃝ Bad Conduct ⃝ Uncharacterized ⃝ Doesn’t Know ⃝ Refused ⃝ Honorable ⃝ General honorable conditions ⃝ Under other than honorable conditions ⃝ Dishonorable ⃝ Bad Conduct ⃝ Uncharacterized ⃝ Doesn’t Know ⃝ Refused ⃝ Honorable ⃝ General under honorable conditions ⃝ other than honorable conditions ⃝ Dishonorable ⃝ Bad Conduct ⃝ Uncharacterized ⃝ Doesn’t Know ⃝ Refused ⃝ Honorable ⃝ General under honorable conditions ⃝ Under other than honorable conditions ⃝ Dishonorable ⃝ Bad Conduct ⃝ Uncharacterized ⃝ Know ⃝ Refused ⃝ Honorable ⃝ General under honorable conditions ⃝ Under other than honorable conditions ⃝ Dishonorable ⃝ Bad Conduct ⃝ Uncharacterized ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Do you receive any VA Compensation or Pension? ⃝ 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 [Skip this page if interviewee is not a veteran]
“Now I’m going to ask you some questions about your health.” Head of Household Person 2 Person 3 Person 4 Person 5 Do you have a physical disability? [E.g. hearing, mobility, and visual impairments] ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused Do you have a developmental disability? [E.g. autism, behavior disorders, and intellectual disabilities] ⃝ Yes ⃝ No ⃝ 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 Head of Household Person 2 Person 3 Person 4 Person 5 Do you have a chronic health condition? [E.g. heart disease, diabetes, severe asthma, traumatic brain injury, dementia, cancer, emphysema, or liver disease] ⃝ 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 ⃝ Know ⃝ Refused Are you living with HIV/AIDS? ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused ⃝ Yes ⃝ No ⃝ Know ⃝ Refused Do you have any mental health issues? [E.g. chronic depression, bipolar disorder, PTSD 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 ⃝ Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5
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 ⃝ 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 drug 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 Head of Household Person 2 Person 3 Person 4 Person 5 Just so I understand what you told me previously, do you have a disability? ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused ⃝ Yes ⃝ No [SKIP to Q 35] ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5 Do you expect this disability to be and impair your ability to live independently? ⃝ 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 Head of Household Person 2 Person 3 Person 4 Person 5 Which disability that we talked about does this refer to? [Mark all that apply] Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Physical Disability Chronic Health Condition Mental Health Issue Substance Abuse ⃝ Doesn’t Know ⃝ Refused Head of Household Person 2 Person 3 Person 4 Person 5