2015 OC PIT Survey – Projects NOT Participating in HMIS

Instructions: Fill in all light yellow cells.
See 2015 PIT Form Instructions for more information.
Additional Help
Refer to HUD’s “2015 HIC-PIT Data Collection Notice” section 4 “Point-in-Time Count Guidance” for additional information.
2015 HIC-PIT Data Collection Notice(PDF)

Organization and Program Information

1.  Organization Name:
(Identify the name of the organization providing shelter or housing to homeless persons).
2.  Project Name:
(The project name should match the project name on all grant applications.)
3.  Date Information is Being Provided (today’s date):
4.  Name of Person Providing Information:
5.  Phone # of Person Providing Information:
6.  Email Address of Person Providing Information:
7.  Name of Agency Director:
8.  Email Address of Agency Director:
9.  Signature of Agency Director:

10. Project Type: (Please check ONE only)

Emergency Shelter (ES)
Transitional Housing (TH)
Safe Haven (SH)
11. This program participates in HMIS? (check one) / Yes / No
a.  If yes, are 100% of the beds in HMIS? (check one) / Yes / No
12.  I certify that project data is complete and correct for the night of the PIT count. (initial)
13.  I certify that that exit dates have been entered for all persons who exited the provider program on or before the date of the PIT. (initial)

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If you need assistance or have questions email or call 714-589-2346

Email completed survey to:

Last Updated: 12/22/14

2015 OC PIT Survey – Projects NOT Participating in HMIS

Population Data

14.  Households with at least one adult and one child
Sheltered Count
Total number of households
Total number of persons
Number of children (under age 18)
Number of young adults (age 18-24)
Number of adults (over age 24)
Gender (adults and children)
Female
Male
Transgender: Male to Female
Transgender: Female to Male
Ethnicity (adults and children)
Non-Hispanic/Non-Latino
Hispanic/Latino
Race (adults and children)
White
Black or African-American
Asian
American Indian or Alaskan Native
Native Hawaiian or Other Pacific Islander
Multiple Races
15.  Households without children
Sheltered Count
Total number of households
Total number of persons
Number of young adults (age 18-24)
Number of adults (over age 24)
Gender
Female
Male
Transgender: Male to Female
Transgender: Female to Male
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Race
White
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Multiple Races
16.  Households with only children (under age 18)
Sheltered Count
Total number of households
Total number children (under age 18)
Gender
Female
Male
Transgender: Male to Female
Transgender: Female to Male
Ethnicity
Non-Hispanic/Non-Latino
Hispanic/Latino
Race
White
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Multiple Races

Veteran Households Only

17.  Veteran Households with At Least One Adult and One Child
Sheltered Count
Total number of households
Total number of persons
Total number of veterans
Gender (veterans only)
Female
Male
Transgender: Male to Female
Transgender: Female to Male
Ethnicity (veterans only)
Non-Hispanic/Non-Latino
Hispanic/Latino
Race (veterans only)
White
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Multiple Races
18.  Veteran Households without Children
Sheltered Count
Total number of households
Total number of persons
Total number of veterans
Gender (veterans only)
Female
Male
Transgender: Male to Female
Transgender: Female to Male
Ethnicity (veterans only)
Non-Hispanic/Non-Latino
Hispanic/Latino
Race (veterans only)
White
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Multiple Races

Youth Households Only

19.  Youth Households
Sheltered Count
Total number of households
Number of parenting youth households
Number of unaccompanied youth households
Total number of persons
Total number of persons in parenting youth households
Number of parenting youth (youth parents only)
Number of parenting youth (under age 18)
Number of parenting youth (age 18 – 24)
Number of children with parenting youth (children under age 18 with parents under age 25)
Total number of unaccompanied youth
Number of unaccompanied children (under age 18)
Number of unaccompanied young adults (age 18 – 24)
Gender (youth parents and unaccompanied youth only)
Female
Male
Transgender: Male to Female
Transgender: Female to Male
Ethnicity (youth parents and unaccompanied youth only)
Non-Hispanic/Non-Latino
Hispanic/Latino
Race (youth parents and unaccompanied youth only)
White
Black or African-American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Multiple Races

Subpopulation Reporting

20.  Homeless Subpopulations
Sheltered Count
Chronically Homeless Individuals
Chronically Homeless Families
Persons in Chronically Homeless Families
Chronically Homeless Veteran Individuals
Chronically Homeless Veteran Families
Persons in Chronically Homeless Veteran Families
21.  Homeless Subpopulations (Adults Only)
Sheltered Count
Adults with a Serious Mental Illness
Adults with a Substance Use Disorder
Adults with HIV/AIDS
Victims of Domestic Violence (optional)

22.  What method did you use to count clients in beds on 1/23/2015? (“X” only one)

Report from Database / Observation (ex. manual counts of people in each required reporting category) / Interviews with sheltered homeless people during the PIT count
Case manager records / Distribution/collection of PIT forms to sheltered homeless people
Other (please specify):

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If you need assistance or have questions email or call 714-589-2346

Email completed survey to:

Last Updated: 12/22/14