2011 State of Hawaii Homeless Persons Point-In-Time County Report

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Appendix 2: 2011 PIT Count Single Survey USE THIS FORM IF THE CLIENT IS SINGLE DRAFT 2011 City & County of Honolulu Homeless Point -in -Time Count Survey Interviewer's Name: Agency /Group: Site of Interview: Date: Introduction Example: "Hello, my name is , and I am an outreach worker /volunteer. We are doing a short survey for an annual homeless count, and your responses will help fund homeless services throughout Hawaii. All of your answers will be confidential. Can I ask you a few questions ?" "Are you living alone or with others ?" If living with others including a child under 18 use HOUSEHOLD form "Where did you sleep this past Tuesday, JANUARY 25 ?" If answer is House or Shelter, then THANK and END SURVEY. "What area of the island did you sleep ?" 1. First Name: 2. Date of Birth: l l 3. Gender: ❑ Male ❑ Female Area or Region # (1 — 7) [Map in back] Last Name: OR if DOB refused, Age: ❑ Transgender ❑ Unknown /Refused 4. Have you served in the U.S. Armed Forces? ❑ Yes ❑ No ❑ Unknown ❑ Refused 5. Were you activated, into active duty, as a National Guard member or Reservist? ❑ Yes ❑ No ❑ Unknown ❑ Refused 6. How long have you been continuously homeless this time? ❑ Less than 1 year ❑ 1 year or longer* 7. How many times have you been homeless in the past 3 years? ❑ 1 — 3 times ❑ 4 or more times* 8. Were you on the street, beach, park or in an emergency shelter each time? ❑ Yes* ❑ No 9. Do you have a mental health, substance abuse or other disabilities that limit your ability to work or perform activities of daily living? ❑ Yes* ❑ No THANK and END SURVEY. ............................................................................................... ............................... ❑ CHECK BOX WHEN THIS SURVEY HAS BEEN ENTERED INTO HMIS :............................................................................................. ............................... . 10