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Appendix 1: 2011 PIT Count Household Survey <br />Interviewer's Name: <br />Site of Interview: <br />USE THIS FORM IF THE CLIENT IS PART OFA HOUSEHOLD <br />(Household is defined as having a child under 18) <br />2011 City & County of Honolulu Homeless Point -in -Time Count Survey <br />Agency /Group: <br />Date: <br />Read Introduction: "Hello, my name is , and I am an outreach worker /volunteer. We are doing a short survey <br />for an annual homeless count, and your responses will help fund homeless services throughout Hawaii. All of your <br />answers will be confidential. Can I ask you a few questions ?" <br />"Are you living alone or with others?" <br />To determine whether to use SINGLE or PART OF HOUSEHOLD form <br />"Where did you sleep this past TUESDAY, JANUARY 25?" <br />If answer is House or Public Shelter, then THANK and END SURVEY. <br />"What area of the island did you sleep ?" <br />Area or Region # (1 — 7) [Map in back] <br />1. Including yourself, how many ADULTS are in your household? <br />2. How many CHILDREN UNDER 18 are in your household? <br />3. How long have you been continuously homeless this time? ❑ Less than 1 year ❑ 1 year or longer* <br />4. How many times have you been homeless in the past 3 years? ❑ 1 — 3 times ❑ 4 or more times* <br />5. HEAD OF HOUSEHOLD <br />First Name: <br />Last Name: <br />Date of Birth: l l OR if DOB refused, Age: <br />Gender: ❑ Male ❑ Female ❑ Transgender ❑ Unknown /Refused <br />Have you served in the U.S. Armed Forces? ❑ Yes ❑ No ❑ Unknown ❑ Refused <br />Were you activated, into active duty, as a National Guard member or Reservist? <br />❑ Yes ❑ No ❑ Unknown ❑ Refused <br />Do you have a mental health, substance abuse or other disabilities that limit your ability to work or perform activities <br />of daily living? ❑ Yes* ❑ No <br />6. OTHER ADULT IN HOUSEHOLD #1: <br />First Name: <br />Date of Birth: l l <br />Last Name: <br />OR if DOB refused, Age: <br />Gender: ❑ Male ❑ Female ❑ Transgender ❑ Unknown /Refused <br />Have you served in the U.S. Armed Forces? ❑ Yes ❑ No ❑ Unknown ❑ Refused <br />Were you activated, into active duty, as a National Guard member or Reservist? <br />❑ Yes ❑ No ❑ Unknown ❑ Refused <br />16 <br />