Tally Restricted To:

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?

Where stayed in the last 30 days

How long have you been in this community or area?

Respondent's age:

Gender:

Ethnicity:

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?

Did you serve in the military?

What level of eduction do you have?

Do you feel you have a disabling condition?

Prior hospitalization for a mental health issue?

Why did you leave your last place of residence (Mark all that apply?)

How many times have you been in homeless in the past 3 years?

HIV/AIDS

How long have you been homeless (this time)?

Substance Abuse

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

Do you receive SNAPS (food stamps)?

This form is being filled out by: