question

Agency: __________________ Program: ________________ Street Address: _______________________ County: _____________ Date Completed (MM/DD/YY): ____________ = IMPORTANT QUESTION!

IF REFUSAL OR OBSERVATION

FILL OUT TABLE ON BACK PAGE!!!

1. Did you already complete this survey this week?  No  Yes IF YES, WHEN: _________________________________

WHERE:_________________________________

th

2. Where did you/will you spend Monday night, January 30 ? (Check only ONE response) If none selected, do not complete the rest of the form    

 Domestic violence shelter  Transitional housing (time-limited)  Safe Haven (Denver Program Only)

Emergency shelter or Cold Weather Shelter (Name of shelter: __________________________) Youth shelter (Name of shelter: __________________________) On the street, under a bridge, in a car, or any other place not meant for human habitation Hotel/motel paid for by a voucher or non profit (If paid by self, do not complete this form)

3. What city & county did you/will you spend Monday night, January 30th? City: ____________________ County:  Adams  Arapahoe  Boulder  Denver  Douglas  Jefferson  Other: (please specify) ____________________ 4. Where was the last room, apartment or house that you lived in for 90 days or more?

City:____________________ County :____________________ State:______

4a. How long have you lived in Colorado?  Less than 1 month  1 month to less than 1 year  1 to 3 years  More than 3 years  Don’t know  Don’t live in CO 5. How long have you been homeless this time? (Check only ONE response)  Less than 1 month  1 month to less than 1 year  1 to 3 years  More than 3 years  Don’t know  I am not currently homeless 6. INCLUDING THIS TIME, how many times have you been homeless in the last three years? (Check only ONE response)  One  Two  Three  Four  Five or more  I have not been homeless at any time in the last three years 7. Did any family members stay in the same place with you on Monday night, Jan 30th? (Check ALL that apply)  Just me  Partner/spouse  Children under age 18  Biological parents/siblings  Service/companion animal 8. Please fill in the following information for yourself as well as any family members staying in the same place with you, on Monday night, January 30th: ADD ADDITIONAL SHEETS IF NEEDED FOR MORE FAMILY MEMBERS! Relationship First 3 First 3 Date of Birth Last 4 to you (spouse letters letters digits or partner, First Last SSN child, parent, Name Name MM DD YYYY sibling, other) WRITE IN Head of household (Yourself)

Gender:

Ethnicity:

Race:

Male (M) Female (F)

Hispanic/ Latino (H)

Transgender (TG) Don’t Identify* (DI)

Non Hispanic/ Latino (N)

American Indian/Alaskan Native (AIAN); Asian (A); Black (B); White (W); Native Hawaiian/Pacific Islander (NHPI); MultiRacial (M)

ONLY COMPLETE FOR INDIVIDUALS AGED 18 AND OVER FOR EACH INDIVIDUAL, CIRCLE ALL THAT APPLY Veteran

Disability

Mental Illness

Alcohol/ drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

Veteran

Disability

Mental Illness

Alcohol or drug abuse

Domestic Violence Victim

HIV/ AIDS

Other chronic health problem

*Don’t identify as male, female, or transgender (DI)

9. Do you have custody of children under age 18 who are not sleeping with you tonight?  Yes (Number of children______________) 9a. If yes, where did they stay on Monday January 30th? 9b. If yes, are you in a:

 Family/friend house

 At another shelter

 On the street

 No  Not sure

 Single parent/guardian household  Dual parent/guardian household

10. In the past month, have you or anyone in your household received any income?  No 11. What contributed to you being homeless now? (CHOOSE ALL THAT APPLY)  Abuse or violence in the home  Alcohol or substance abuse problems  Asked to leave  Bad Credit  Discharged from foster care  Discharged from jail  Discharged from prison  Family member or personal illness  Legal Problems  Other___________________________________________________ 

 Yes, from work  Yes, from SSI/SSDI  Yes, from other: ____________

 Lost job/Couldn’t find work  Medical Expenses  Mental illness  Moved to find work  Problems with public benefits  Reasons related to my sexual orientation  Relationship problems or family break-up  Unable to pay utilities  Unable to pay rent/mortgage  Doesn’t apply to me

REFUSAL/OBSERVATION SECTION- ONLY COMPLETE IF YOU CANNOT COMPLETE AN INTERVIEW! Use only on night/day of Point in Time. 1. Check one:  Refusal

 Observation

2. Reason for Refusal/Observation:  Unable to enter site  Do not wish to disturb people sleeping

 Language barrier (Language spoken:_____________)  Other: ________________________

3. Where is the individual spending the night of January 30th? (Check only ONE response)  Emergency shelter or Cold Weather Shelter  Domestic violence shelter Name of shelter:  Hotel/motel paid for by a voucher or non profit Youth shelter  Transitional housing (time-limited)  On the street, under a bridge, in a car, or any other place not meant for human habitation Name of shelter: _______________________________  Safe Haven (Denver Program Only) 4. Does this person have family members with them? 

 No

 Don’t Know

 Yes, Children (# of children ________)  Yes, Adults (# of Adults ________)