Select Item to Tally:

Tally Restricted To:

No Restrictions

Restrict Tally to Specific Answers:

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 Thursday, January 26th?

On the night of January 24th, are you or were you on a reservation? If so, which one:

Where did you stay during the prior week?

How long have you been in this community?

Respondent's age:



Are you alone or with family:

Are you or anyone else with you pregnant?

Ages of family members who are living with you and not filling out a survey.

If any of the above (family with you) are school aged children are they in school now?

What level of eduction do you have?

(Marked one or more disabilities)

Do any of the following disabling conditions prevent you from living on your own and are expected to last a long time? (check all that apply):

What services or assistance would you most need today to become housed?

What service or assistance would have helped you the most to stay in your last home?

Why did you leave the last place you considered home (check all that apply?)

If you have been without a home or permanent place to live before how many times in the last 3 years?

How long has it been since you had a place you considered home or a permanent place to live?

Have you served on active duty in the U.S. Armed Forces (e.g. served in a full-time capacity in the Army, Navy, Air Force, Marine Corps, or Coast Guard)?

Wereyou ever called into active duty as a member of the National Guard or as a Reservist?

Do you have any income (check all that apply)

Are you or your family receiving any of the following Non-Cash Benefits? (check all that apply)

This form is being filled out by: