Homelessness Knowledge Development Unit (HKDCEU) / …



SURVEYSurvey Number: XXXXLocation: Time: AM/PM Interviewer: Contact #: UNIQUE IDENTIFIERFirst Name Initial _______ Last Name Initial ________ Month of Birth [1-12] ________ Day of Birth [1-30] ______6 Digit ID [EX. JD1220] _____ _____ _____ _____ _____SCREENING QUESTIONS Do you have a permanent residence that you can return to tonight?YESNODON’T KNOWDECLINE TO ANSWERWhere are you staying tonight?PUBLIC SPACE (E.G., SIDEWALKS, SQUARES, PARKS, FORESTS, BUS SHELTER) VEHICLE (CAR, VAN, RV, TRUCK) MAKESHIFT SHELTER, TENT OR SHACKABANDONED/VACANT BUILDING OTHER UNSHELTERED LOCATION UNFIT FOR HUMAN HABITATION (SPECIFY)_____________RESPONDENT DOESN’T KNOW [LIKELY HOMELESS]BEGIN SURVEYWhat family members are with you? [Indicate survey numbers for adults]NONEPARTNER - Survey #: ___ ___ ___ ___OTHER ADULT - Survey #: ___ ___ ___ ___DECLINE TO ANSWERCHILD(REN)/DEPENDENT(S) [indicate age for child/dependent]12345678910GENDERAGEHow old are you? [OR] What year were you born? [If unsure, ask for best estimate]AGE ________OR YEAR BORN _____________DON’T KNOWDECLINE TO ANSWERIf youth is under the age of 15, terminate survey, tally and notify Team Leader and/or shelter and service staff.What gender do you identify with? [Select one. Do not read categories]MALEFEMALETRANSGENDERTRANS WOMANTRANS MANTWO-SPIRITGENDERQUEERGENDERFLUIDANDROGYNOUSNON-BINARYINTERSEXDON’T KNOWDECLINE TO ANSWERDo you identify as part of the Lesbian, Gay, Bisexual, Two-Spirited or Queer, community?YESNODON’T KNOWDECLINE TO ANSWERDo you identify as Aboriginal or do you have Aboriginal ancestry? This includes First Nations, Métis, Inuit, with or without status. (Note: You may consider including “Indigenous” or locally-used terminology here, in consultation with your community.) [If yes, please follow-up to specify.]YES --------------------------------------------->NODON’T KNOW DECLINE TO ANSWERIf YES:FIRST NATIONSINUITM?TISNON-STATUS / HAVE ABORIGINAL ANCESTRYDid you move to [COMMUNITIY] in the past year?YESNODON’T KNOWDECLINE TO ANSWER 6B. If you moved to [COMMUNITY] in the last year, where were you living prior to coming here?COMMUNITY NAME___________________AND PROVINCE_______________________OR COUNTRY_________________________DON’T KNOWDECLINE TO ANSWERDid you come to Canada as an immigrant or refugee within the past 5 years?YESNODON’T KNOWDECLINE TO ANSWERWere you born in Canada?YES NO ------------------------------>DON’T KNOW DECLINE TO ANSWERIf NO:CANADIAN CITIZENPERMANENT RESIDENTREFUGEE CLAIMANTTEMPORARY FOREIGN WORKERINTERNATIONAL STUDENTOTHER (PLEASE SPECIFY)_____________________Over the past year, how much of the time have you been homeless? [Best estimate.]LENGTH ______________ DAYS / WEEKS / MONTHS DON’T KNOW DECLINE TO ANSWERIF UNSURE:0-2 MONTHS3-5 MONTHS6-12 MONTHSOver the past year, how many different times have you experienced homelessness? [Includes this time. Best estimate.]NUMBER OF TIMES __________________________DON’T KNOW DECLINE TO ANSWERIF UNSURE:1 TIME [current episode]2 TIMES3 OR MORE TIMESHow old were you when you first became homeless in your life?AGE___________DON’T KNOWDECLINE TO ANSWERHave you stayed in an emergency shelter in the past year?YESNODON’T KNOWDECLINE TO ANSWER 12B. If “NO”, why not?DON’T KNOWDECLINE TO ANSWERWhat happened that caused you to lose your housing most recently? [Do not read the options. Select all that apply. “Housing” does not include temporary arrangements (e.g., couch surfing) or shelter stays.]ILLNESS OR MEDICAL CONDITIONADDICTION OR SUBSTANCE USEJOB LOSSEVICTED: UNABLE TO PAY RENTEVICTED: OTHER REASONDOMESTIC ABUSE: SPOUSE OR PARTNER DOMESTIC ABUSE: PARENT OR GUARDIANFAMILY CONFLICT: SPOUSE OR PARTNERFAMILY CONFLICT: PARENT OR GUARDIANCONFLICT WITH A ROOMMATELEFT CARE (CHILD PROTECTION)/[PROV. TERM]INCARCERATED (JAIL OR PRISON)HOSPITALIZATION OR TREATMENT PROGRAMUNSAFE HOUSING CONDITIONSDON’T KNOWDECLINE TO ANSWEROther reason/Notes:What is the highest level of education you completed?ELEMENTARYSOME HIGH SCHOOLHIGH SCHOOL GRADUATESOME POST SECONDARY POST SECONDARY GRADUATEDON’T KNOWDECLINE TO ANSWERAre you currently attending school?YESNODON’T KNOWDECLINE TO ANSWERAs a child, were you ever involved with child protection services (also known as children’s aid or the child welfare system)?YESNODON’T KNOWDECLINE TO ANSWERHave you ever been in foster care and/or group home?YESNODON’T KNOWDECLINE TO ANSWERDo you want to get into permanent housing?YESNODON’T KNOWDECLINE TO ANSWERWhat do you think is keeping you from finding a place of your own? [Select all that apply]LOW INCOMENO INCOME ASSISTANCERENT IS TOO HIGHPOOR HOUSING CONDITIONSDOMESTICK VIOLENCEHEALTH/DISABILITY ISSUESMENTAL HEALTH ISSUESADDICTIONFAMILY BREAKDOWN/CONFLICTCRIMINAL HISTORYPETSCHILDRENDISCRIMINATION DON’T WANT HOUSINGOTHER (PLEASE SPECIFY)___________________NO BARRIERS TO HOUSINGNONE OF THE ABOVEDECLINE TO ANSWERWhat would help you find permanent, stable housing?___________________________________________DON’T KNOWDECLINE TO ANSWER ................
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