Introduction.docx - Introduction Section A Background...

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Section A: Background Surveyor’s Name: ______________________________________________________________ Location of Survey: _______________________________ Time of Survey: ___________ 1. Which racial/ethnic group do you identify the most? (Check only one box.) a. African American or black d. Hispanic or Latino b. Caucasian or white (non-Hispanic) e. Other single race: ____________ c. Asian or Pacific Islander f. Other multi-racial: ____________ 4a. Have you ever served in the military? (Check only one box.) a. Yes b. No (Skip to question 5) 4b. If yes, what branch of the military did you serve? (Check all that apply .) a. Army, including Reserve or d. Air Force, including Reserve or National Guard National Guard b. Marine Corps, including Reserve e. Cost Guard, including Reserve c. Navy, including Reserve 4c.What were your enlistment and discharge years? (Write years on lines) Enlistment Year: ____________________ Discharge Year: ________________ 4d.What type of discharge did you receive? (Check only one box.) a. Honorable discharge e. Bad conduct discharge b. General discharge f. Dishonorable discharge c. Other than honorable discharge g. Dismissal d. Entry-level separation h. Other: _______________________ 4e. Are you a war veteran? (Check only one box.) a. Yes b. No (Skip to question 5)
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4f. Which war zone(s) did you serve in? (Check all that apply.) a. Vietnam War e. Persian Gulf War/Operation Desert Storm/First Iraq War b. Lebanon f. Operation Enduring Freedom/War in Afghanistan c. Grenada g. Operation Iraqi Freedom/Second Iraq War d. Panama h. Other War Zone: _____________________________________ 5. What is your marital status? (Check only one box.) a. Never married c. Married e. Widowed b. Separated d. Divorced 6a. Do you currently live with any members of your family, such as spouse, parent, sibling or children? (Check only one box.) a. Yes b. No (Skip to question 7) 6b. For each family member currently living with you, please tell us his or her age, gender and relationship to you. Relationships can be child, spouse, partner, sibling, etc. (Do not include self/respondent.) Person 1. Age: ______ Gender: ___________ Relationship to you: _______________ Person 2. Age: ______ Gender: ___________ Relationship to you: _______________ Person 3. Age: ______ Gender: ___________ Relationship to you: _______________ Person 4. Age: ______ Gender: ___________ Relationship to you: _______________ Person 5. Age: _______ Gender: ___________ Relationship to you: _______________ Person 6. Age: _______ Gender: ___________ Relationship to you: _______________ 9. What are the primary reasons that caused you to become homeless? (Check all that apply.) Substance abuse (SA): - Alcohol or drug use - Completed, terminated, or voluntarily - Other substance abuse factor: _____ left treatment program Economic factors: - Loss/lack of money or funds - Lost job (unemployment) - Unable to pay rent or mortgage
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- SSI/SSD cut off or benefits canceled - Other economic factor: __________ Family factors: - Death in family - Argument with family - Family violence - Divorce - Other family issue: ______________ Health factors: - Illness or medical problem - Mental illness - Released from hospital - Physically disabled - Other health issue: _____________ Housing factors: - Foreclosure - Eviction - Other housing issue: ____________ - Not able to obtain public - Relocation, transition or from out housing or Section 8 of town - Can’t find affordable housing - Aged out of foster care - Other issues: ___________________ Other factors: - Runaway from home - Released from jail or prison - Kicked out of home 10. How many different times have you been homeless (without a permanent place to live) during the last 3 years, including this time? (Check only one box.)
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