1|Page2017 Western (Harrisonburg/Winchester) Continuum of Care Point in Time Count

2017Housing Needs & Vulnerability Survey

a. Interviewer’s Name / b. Interviewer’s Status
Staff Volunteer
c. Date / d. Time / e. Location
In what language do you feel best able to express yourself?
g. First Name / h. Last Name
Nickname / j. Date Of Birth MM/DD/YYYY
k. Gender (Are you male, female or transgender?) / l. Respondent ID = First Initial + Last Initial + Birth Month + Day + Year (MMDDYYYY) + Gender (M or F)*
m. Social Security Number
(last 4 digits) / n. Has signed consent to participate:
 YES  NO

If you have any questions, please call Laura Black at (540) 908-0415

Please do not give survey directly to respondent.

This page will not be stored with the survey. Survey names will be kept confidential.

Introduce yourself by your first name and politely ask for 10-15 minutes of time.

  • “We are conducting a count and survey of people who are homeless.”
  • “Your participation will help provide better programs and services for people who are homeless.”
  • “The information on the survey will not have your name included, we will assign an ID number”
  • “Would you be willing to participate in the survey?

“Have you already completed a survey about where you are staying/stayed on Wednesday, January 25th?

If “No”, continueto administer the survey
If “Yes” Stop and thank them for their time.

Leave Blank.

NOTE TO SURVEYOR:

Wherever respondent does not know or refuses to answer, write in DK (don’t know) or REF (refused).

Please fill out ID using the information gathered on the last page

Respondent ID = First Initial + Last Initial + Birth Month + Day + Year (MMDDYYYY) + Gender (M or F or T)

ID#______(example JA03051962M)

Survey Location______Time ______

  1. May I ask your race?

 White/Caucasian  Black/African American

 Asian Native Hawaiian/Other Pacific Islander

 American Indian/Alaska Native  Multi-Racial ______

 Other ______

1a. Are you Hispanic/Latino?

 Non-Hispanic/Latino  Hispanic/Latino

2. Which best describes who is with you tonight/or was with you on January 25th?

 Individual, without children (skip to Q.5 – next page)  Couple, without children (skip to Q.5)

 Two-parent household  Single parent household

 Other: ______

3. Do you have children under 18 with you tonight? ______(Any child who is physically under the Head of Household respondent’s care at the Point-in-Time should be included. Children who live with another family member or will be with another person tonight should not be counted).

Child 1, age ______gender ______race(s) ______Hispanic/Latino Y or N

Child 2, age ______gender ______race(s) ______Hispanic/Latino Y or N

Child 3, age ______gender ______race(s) ______Hispanic/Latino Y or N

  1. If respondent has children between the ages of 5 and 17 with them,
    are the children enrolled in school? Where? (record with head of household respondent only)

School:______
(City state if not local) ______

I would like to ask you a few questions about your housing history…

  1. Where will you/did you sleep tonight/Wednesday night, January 25th?______
  2. Where do you sleep most frequently? ______
  3. Is this the first time you have been homeless?  Yes  No
  4. How long have you been homeless this time (what date did it start, approx.)? ______
  5. How many separate timeshave you been homeless or on the street in the past 3 years (since January 2014).
    including this time?______
    (example: homeless, then housed for 7 days or longer, then back to homeless counts for 2 episodes )
  6. Total number of months homeless on the street or in Emergency Shelter in the past three years _____ months
  7. How long would you estimate you have been homeless during your life-time? ______months______years
  8. Where was the last place you had housing for 90 days or more (not a shelter but a place where you could get mail)?

Name of City / County: ______

Name of State:______

  1. How long have you lived in this area/city? ______Years______Months
  1. Do you have any long-term disabilities or conditions that keep you from holding or keeping a job or living in stable housing? These include physical problems, illnesses, substance or mental health issues  Yes  No
  1. What are the main reasons you became homeless? (Check all that apply)

 Family/personal illness  Released from substance abuse treatment  Unemployment

 Residence condemned/destroyed  Physical/mental disabilities

 Dispute with family/friends Moved to seek work

 Unable to pay rent/mortgage Addiction

 Divorce/dispute with spouse  Plans with family/friends fell through

 Domestic violence  Released from jail/prison

 Evicted  Released from mental health treatment

  1. Below is a list of common characteristics and challenges experienced by those without a home.
    Please indicate which ones affect you: (check all that apply)

 Cannot Find Work  Cannot Find Affordable Housing

 Medical Problems Dental Problems Legal Problems/Problems with Police

 Child Custody Disputes  Challenges with Substance Abuse
 Transportation  Other ______

I’d like to ask you a personal few questions about your health if I may?
This information helps local healthcare providers and clinics plan for outreach programs.

  1. Would you say that in general your health is:
 Excellent  Very Good  Good  Fair  Poor
  1. How easy is it to get health care when you need it?
     Very Easy  Easy  Somewhat Difficult  Very Difficult  I have not needed health support
  1. Including physical illness and injury, how many days during the past 30 days was your physical health not good? _____
  1. In the past 30 days, how much of the time did you experience stress, depression and/or problems with emotions?
 All the time
 Most of the time
 A good bit or the time
Some of the time
A little of the time
None of the time
  1. During the past 30 days, how often did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? _____
 All the time
 Most of the time
 A good bit or the time
 Some of the time
 A little of the time
 None of the time
  1. Have you needed to go to the Emergency Room in thepast 3 months?, if so, how many times?_____
    In the past 12 months? ______
  1. How many times have you been admitted to the hospitalin the past year? _____
  1. How many total days did you stay in the hospital in the past year? _____
  1. Do you have any health insurance? If so, what kind? (check all that apply)
 Medicaid  Medicare  VA  Private Insurance  None  Other
  1. Where do you usually go for healthcare or when you’re not feeling well?
 Rockingham Memorial Hospital  Harrisonburg Rockingham Community Health Center
 Harrisonburg Rockingham Free Clinic Suitcase Clinic– Rockingham County
 Shenandoah Memorial Hospital  Warren Memorial Hospital
 Winchester Medical Center  Page Memorial Hospital
Free Medical Clinic of the Northern Shenandoah Valley
Does not go for care
 Other ______
  1. May I ask some personal questions about your medical history?  Yes  No
    This helps local health providers with planning for care
    Do you have now, have you ever had, or has a healthcare provider ever told you that you have any of the following medical conditions?

  1. Kidney disease/ End Stage Renal Disease or Dialysis  Yes  No
  2. History of Frostbite, Hypothermia, or Trench Foot  Yes  No
  3. History of Heat Stroke/Heat Exhaustion  Yes  No
  4. Liver disease, Cirrhosis, or End-Stage Liver Disease  Yes  No
  5. Heart disease, Arrhythmia, or Irregular Heartbeat  Yes  No
  6. HIV+/AIDS  Yes  No
  7. Emphysema  Yes  No
  8. Diabetes “sugar”  Yes  No
  9. Asthma  Yes  No
  10. Cancer  Yes  No
  11. Hepatitis B or C  Yes  No
  12. Tuberculosis  Yes  No
  13. High blood pressure  Yes  No
  14. Arthritis  Yes  No
  15. COPD/pneumonia  Yes  No
  16. Other ______(e.g. pregnancy, developmental disability)
  1. DO NOT ASK: Surveyor, do you observe signs or symptoms of serious
    physical health conditions? Yes  No

  1. Have you ever abused or been told that you abuse…
    Drugs  Yes  No
    Alcohol  Yes  No
  1. On average, in the past month, how many days a week have you had an alcoholic drink? ______
    On a typical day that you drink, how many drinks do you have? ______
  1. Have you ever used injection drugs or shots? Yes  No
  1. Have you ever been treated for
    Drug abuse  Yes  No
Alcohol abuse  Yes  No
  1. DO NOT ASK: Surveyor, do you observe signs of symptoms of alcohol or drug abuse?
     Yes  No

  1. Are you currently or have you ever received treatment for mental health issues?  Yes  No
    if yes, have you had a mental health admission in the last year?  Yes  No
  1. DO NOT ASK: Surveyor, do you detect signs or symptoms of severe,
    persistent mental illness?  Yes  No

  1. Have you been the victim of a violent attack since you’ve become homeless?  Yes  No
  1. Do you have a permanent physical disability that limits your mobility?
(i.e., wheelchair, amputation, unable to climb stairs) Yes  No
  1. Have you had a serious brain injury or head trauma that required hospitalization
    or surgery?  Yes  No

May I ask some questions about Military Service?

  1. Have you ever served in the US Military  Yes (answer 29-32)  No (Skip to question 33)
  2. Have you ever received health care/benefits from a VA Center?  Yes  No
  1. Which branch did you serve in? ______

 Army Navy Air Force Marines Coast Guard
National Guard Reservist Other______

  1. Are you a combat veteran? …………………………………………… Yes  No
  1. If yes, which war/war era did you serve in?

 Korean War (1950-1955)  Vietnam Era (1964-1975)  Post Vietnam (1975-1991)

 Persian Gulf Era (1991-Present)  Afghanistan (2001-Present)  Iraq (2003-Present)

Other ______

  1. What was the character of your discharge?

 Honorable  Other than Honorable  Bad Conduct  Dishonorable

  1. Your answers will remain confidential. May I ask your citizenship status?
     Citizen  Legal Resident  Undocumented
  1. What is your level of education?

 Less than High School?
 High School Graduate or GED
 Some College, Trade School or Associates Degree
 Bachelor’s Degree
 Graduate or Professional Degree

  1. Did you receive special education services in High School?  Yes  No
  1. Childhood Experiences: as a child;

Were you ever in foster care?  Yes  No if yes, for how long? ______

Did you suffer childhood trauma, abuse or neglect  Yes  No

  1. May I ask, have you ever been in jail?  Yes  No
  1. May I ask, have you ever been in prison?  Yes  No

Employment

  1. Are you currently employed? Yes  No

If no, what do you feel are your barriers to employment?

 Transportation  Job Skills or Training  Job Opportunities Childcare
 Other: ______

  1. What sources of income have you received in the last 6 months? (check all that apply)

Employed Full Time (30 hrs/week): Occupation: ______

Employed Part Time (30 hrs/week): Occupation: ______

 TANF Unemployment Insurance

 Food Stamps  Disability (SSI)  Disability (SSDI)

 Veteran’s Benefits  Relatives/Friends  Churches

Social Security  Community Agency
Child Support  Pension

 Other ______ None

  1. What sources of income have you applied for but could not get in the last 6 months? (check all that apply)

 TANF  Unemployment Insurance

 Food Stamps  Disability (SSI)  Disability (SSDI)

 Veteran’s Benefits  Relatives/Friends  Social Security

 Pension  Child Support  Other ______

  1. To better understand services you need, can you tell us if you used or tried to get these services?

Used Service / Tried but
could not get / Didn’t seek / Didn’t know
Sample / X
  1. Emergency Shelter:

  1. Permanent housing placement

  1. Job Training/Job placement

  1. Substance abuse services

  1. Mental health services

  1. Food pantry/meals

  1. Vouchers for transportation

  1. GED or English classes

  1. Emergency financial assistance

  1. Legal Aid

  1. Childcare assistance

  1. Medical services

  1. Medical assistance

  1. Dental assistance

  1. Community drop-in center (day shelter)

  1. Domestic violence services

  1. Medication

  1. School enrollment assistance for homeless children (k-12)

  1. Other ______

Thank you for so much of your time.Did this survey make you think of anything else you want to say?

Don’t forget the gift

Notes
Keep notes confidential

NOTE TO SURVEYOR:

Wherever respondent does not know or refuses to answer, write in DK (don’t know) or REF (refused).