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Homeless as defined by HUD (all cases)

HUD Homeless: stayed at sheltered place

HUD Homeless: stayed at unsheltered place

HUD Homeless: chronically homeless

HUD Homeless: mentally ill

HUD Homeless: substance abuser

HUD Homeless: both mentally ill and substance abuser

HUD Homeless: domestic abuse victim

Location (District):

Where are you sleeping or where did you sleep on Tuesday, January 29th?

How long have you been at this place?

Are you being discharged or asked to leave any of the above loctions within 1 week without a place to live or the resources to obtain housing?

How long have you been in this community or area?

Have you lived in this community your entire life?

Your age:



Please indicate whether you are alone or with family

Are you or anyone else with you pregnant?

If with family members, please provide their ages:

If with school-aged children, are they currently enrolled in school? If not, when were they last enrolled in school?

Did you serve in the military?

What level of eduction do you have?

Are you currently disabled with a diagnosed condition? Please indentify (mark all that apply).

Have you been diagnosed with any of the following:

Are you homeless due to any of the following (Mark all that apply?)

Have you been homeless more than once in the past 3 years? If so, how many times?

Have you been homeless more than once in the past year?

How long have you been homeless (this time)?

Before you became homess (this time), where were you living?

Do you have any source of income (check all that apply)?

Do you receive any of the following benefits (check all that apply)?

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