AYCNA Survey FINAL VERSION 2.0.pdf - 2015 Atlanta Youth...

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2015 Atlanta Youth Count Survey START TIME ___________(AM/PM) DATE: _____ /_____/2015 LABEL HERE TEAM / INTERVIEWER ID ____ /______ INSTRUCTIONS: COMPLETE ONE FORM PER INDIVIDUAL ENCOUNTERED. DO NOT READ INSTRUCTIONS OR RESPONSES IN CAPITAL LETTERS! Thank you for agreeing to participate in our study. Again, my name is (YOUR NAME) . Some of the questions we ask are very personal and might make you feel uncomfortable. Please know that we wouldn’t ask these questions if they weren’t important. Remember if a question is too personal, you don’t have to answer it. Let’s begin. 1. Within the past month, has a service provider or outreach worker given you an LED keychain like the one in this picture (SHOW PICTURE) ? YES NO 2. What is the first letter of your legal last name? |___| 3. On what day of the month were you born? I don’t need your full birthdate, just the day. For example, if you were born on April 30 th your response would be the number 30. X X / |___|___| / X X X X 4. Where were you born? (PROBE FOR CITY, STATE OR, IF OUT OF USA, CITY AND COUNTRY) CITY: _________________ STATE: |___|___| COUNTRY:__________________ 5. What sex were you assigned at birth? Male/man Female/woman Something Else, Specify ________________________ 6. Do you consider yourself (READ ALL OPTIONS AND CHECK ALL THAT APPLY) . Man/male Woman/female Part-time in both Gender queer Transgender Intersex Gender non-conforming Something else/specify: _______________________________
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7. Which of the following labels best describes your sexual orientation? Straight or Heterosexual Gay or Lesbian Bisexual Something else? SPECIFY: _______________________ STILL UNDECIDED/QUESTIONING 8. Do you consider yourself to be Hispanic or Latino? YES NO 9. What race do you consider yourself? (PLEASE CHECK AT LEAST ONE AND ALL THAT APPLY.) WHITE BLACK OR AFRICAN AMERICAN ASIAN NATIVE AMERICAN/ALASKA NATIVE PACIFIC ISLANDER MULTI-RACIAL OTHER/SPECIFY: ________________________________ 10. Where did you sleep last night? (RECORD VERBATIM; CHECK ONE THAT APPLIES) (IF * ASK FOR FACILITY NAME) ___________________________________________________________________________ MY OWN HOUSE OR APARTMENT WITH BIOLOGICAL FAMILY IN THEIR HOUSE WITH CHOSEN FAMILY IN THEIR HOUSE WITH FRIENDS IN THEIR HOUSE HOTEL/MOTEL GROUP HOME/PERSONAL CARE HOME EMERG SHELTER/DOM VIOLENCE SHELTER* TRANSITIONAL HOUSING* PERMANENT SUPPORTIVE HOUSING* JAIL/PRISON* DETOX CENTER* MEDICAL/PSYCH HOSPITAL/FACILITY* *FACILITY NAME:___________________________________________ IN A CAR/TRUCK/OTHER VEHICLE ON THE STREET/SIDEWALK/IN A PARK UNDER A BRIDGE OR OVERPASS IN THE WOODS OR CAMPSITE BUS OR TRAIN STATION OR AIRPORT ABANDONED BUILDING OR FARM STRUCTURE OTHER (SPECIFY): ________________________________________
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11. Do you expect to be able to stay where you are currently living for at least two weeks? YES NO 12. How long have you been homeless this time (that is, continuously homeless since your last permanent housing)? < 1 MONTH >3-6 MONTHS 1-2 MONTHS >6 MONTHS TO 1 YEAR >2-3 MONTHS >THAN 1 YEAR 13. Over the past month, have you been contacted or received services from any of the following programs or agencies? (CHECK ALL THAT APPLY ) Covenant House Salvation Army CHRIS Kids Sconiers Homeless Preventive Organization Hope Atlanta Someone Cares Lost-N-Found Stand Up for Kids Mercy Care Young People Matter Another organization? SPECIFY: ______________________ 14. Do you currently receive any type of rental assistance or hotel/motel voucher from an
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