8/8/2019 2011 Sheltered and Unsheltered BoS PIT Survey

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County______________________Date_____________Interviewer____________________________Place of Contact________________________

  Homeless Individual Assisted with Survey  Survey completed without input from individual

STATE OF WEST VIRGINIA- Homeless Demographic & Needs Survey 2011Instructions: COMPLETE ONE SURVEY FOR EACH ADULT OR UNACCOMPANIED HOMELESS CHILD BETWEEN

4PM, JAN 27, 2011 THROUGH 3:59PM, JAN 28, 2011

If the respondent is residing with a family group, then any information for minor children should be recorded with the head of 

household’s responses. A separate survey must be completed for each additional adult household member  

1. * Where did you/will you sleep on the night of Thursday, Jan. 27? 

 *On the street (vehicle, tent, park, abandoned building, structure without utilities, unlocked public building, etc.)

 *Emergency shelter (facility, vouchers or HPRP funded Hotel/Motel Vouchers)

 *Transitional housing program (apartment or facility)

 *Seasonal Shelter

 *Hospital, treatment facility or other type facility/institution for past 30 days AND was homeless prior to entering the facility

(substance abuse, mental health, jail)

 Permanent Supportive Housing Program

 In a private dwelling that I own or rent (room, apartment, house)

 With a family/friend in their private dwelling

 In a motel/hotel

 In some other homeless situation, specify: ________________________ No answer/refused

1a. *Will you be evicted, discharged, foreclosed upon, or forced to leave your current housing situation within 7 days AND lack the

resources to remain in housing or obtain housing?  

  Yes   no   No answer/Refused

1b. (Families/Youth Only) Have you had a lease or ownership to housing in the past 91 days? 

  Yes   no   No answer/Refused

1c. (Families/Youth Only) Have you moved three or more times in the past 90 days? 

  Yes   no   No answer/Refused

2. *How many times have you been homeless, lived on the street or in an emergency shelter in the past three years?  

 None  One  Two  Three  Four or More  No Answer/ Refused

3. *How long have you been homeless this time?   One week or less

 More than one week, but less than one month

 One to three months 

 More than three months, but less than one year

 One year or longer

 Not homeless

 No answer/refused

4. *Have you been diagnosed with any of the following disabilities or long-term physical illnesses? If yes, check all that apply.

 Addiction to alcohol or drugs

 Other addictions (e.g. gambling)

 Mental Illness (e.g. depression, bipolar, schizophrenia)

 HIV/AIDS

 Other long-term physical illness (e.g. cancer, hepatitis) 

 Physical Disability

 Developmental Disability

 Other: please specify: _________________________

 No Answer/refused 

(A) *Respondent Descriptor:  ____ Single Individual   ____Head of Household (HOH) w/children ____Another adult member of a household (not HO

 ____ Unaccompanied Child (under 18) with or without children

(B) Respondent Identifier: ______________________________First Initial of First Name + First Initial of Last Name + Birthdate (00/00/0000) + Gender (M/F/

For example: John Smith – JS03141953M

(C) *For a family, or unaccompanied child, with children, list the gender and age of each minor child (RECORDED WITH HOH ONLY) 

#1:___M___F____Age #2:___M___F____Age #3:___M___F____Age

#4:___M___F ____Age #5:___M___F____Age #6:___M___F____Age

(D) *If respondent is/has children between the ages of 5 and 17, are they currently enrolled in school? (RECORDED WITH HOH ONLY) ___YES___NO 

(E) *Are you a victim of Domestic Violence:  ____YES ____NO (F) *Have you served in the U.S. Armed Forces?  ____YES ____NO

(G) *Were you activated, into active duty, as a member of the National Guard or as a Reservist?   ____YES ____NO

8/8/2019 2011 Sheltered and Unsheltered BoS PIT Survey

http://slidepdf.com/reader/full/2011-sheltered-and-unsheltered-bos-pit-survey 2/2

County______________________Date_____________Interviewer____________________________Place of Contact________________________

  Homeless Individual Assisted with Survey  Survey completed without input from individual

5. What is your reason for being homeless (mark up to FIVE that are MOST appropriate):

  Disability

  Unemployment/Underemployment

  Severe Housing Cost Burden

  Release from Prison

  Eviction 

  Substance Use

  Mental Illness

  Dual Diagnosis (both Mental

Illness and Substance Abuse)

  HIV/AIDS 

  Domestic Violence

  Child Abuse/Neglect

  Runaway

  Natural Disaster

  Legal problems

  Aging out of Foster Care6. Which of the following is a source of income for your household? (check all that apply)  

  Wages from employment   Veteran’s Benefits 

  Disability (SSI/SSDI)   TANF

  Food Stamps   Social Security/Pension

  Friends and Family   Child Support

  Other,specify:__________________________________________________________________

7. Where was the last place you were housed for 90 days or more?  

  This county   Another state in the US, specify, _______________

  Another county in WV, specify ________________    Another country, specify, ____________________

8. What is the highest level of formal education that you completed?

  No formal education   6th grade or less   9th grade or less

  High school diploma/GED   Some high School   Vocational/Technical/Associates Degree

  Some College   College Graduate   Post Graduate Education   No Answer/Refused

9. What Ethnic Group do you identify most with? 

  Hispanic/Latino   Non-Hispanic/Latino   No answer/refused

10. What Race do you identify most with? 

  Caucasian/White

  American Indian/Alaskan Native

  Other: _____________________

  African-American/Black

  Multi-Racial

  Don’t Know 

  Asian

  Native Hawaiian/Pacific Islander

  No answer/refused

11. Which of the following have you received or needed and been unable to obtain in the past twelve (12) months, if any? (check all that apply)

Received Unable to

obtain

Received Unable to

obtain

Addiction Treatment     Medical Treatment    Child Care Assistance     Mental Health Services    Disability Services     Supportive Housing for the

Disabled

   Food Assistance     Transportation Assistance    Health Insurance     Domestic Violence Services    Emergency Shelter     Showers    Transitional Shelter     Medication    Job Training/Employment

   Respite Care

   Legal Services     Education    Veteran’s Services      Clothing/Personal Hygiene

Items

   

Please use the space below to allow the respondent and/or the interviewer to make comments or include additional information

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