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CORONAVIRUS (COVID-19) RESOURCE CENTER Read More

Sutter-Yuba Homeless Consortium
Point-in-Time Count
January 26-30, 2015

Interviewer/Survey provider: please fill in the location of the survey and your name. Also, be sure to identify the place where the person(s) surveyed will sleep to be completed on this form. Also, if the place was a shelter, be sure the type of facility***** is accurate. Thank you.

TO THE PERSON(S) IDENTIFIED ON THIS FORM:

Place or Name of Facility where you will sleep.


Sheltered:

Emergency Shelter
Transitional Housing
Domestic Violence Shelter
Hotel/motel/apt voucher
Other:

Unsheltered:

In vehicle
Non-residential building
Tent encampment
Street/doorway/underpass
Other:

Permanent Supportive Housing:

Residential Mental Health
Other:
Precariously Housed:
Doubled up with another family or friends

Please fill in the boxes below. This series of 10 letters and numbers will be the identification for this survey that does not reveal your full name of the Head of Household. required


First Name Initial

Middle Initial

Last Name Initial

DOB: M M

DOB: D D

DOB: Y Y

Male/Female/Other

Additional household members living with you are:

Spouse/Partner:

Child:

Child:

Child:

Child:

Child:

Are you or any household member included in any of these categories?

Yourself

Household Member

Unaccompanied youth (under 18)

Victim of domestic violence/Criminal abuse

Person with HIV/AIDS

US Military Veteran

Chronic Substance Abuser

Severely Mentally Ill

Senior Age 55+

How long have you been homeless this time? Since:  
How many separate times have you been homeless in the last three years?  
Approximate dates the last 3 years when homeless:  
Do you have any disabling conditions not mentioned in the categories above? Please list
Access to restroom & shower?  
Access to meals?