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Harford County Unsheltered Count Form

  1. Interview Information

  2. Dialogue

  3. Hello, my name is __(your name)___ and I'm a volunteer for Harford County's Homeless Services. We are conducting a survey of people experiencing homelessness to provide better programs and services to them. Your participation is voluntary and your responses to questions will not be shared with anyone outside of our team. I need to read each question all the way through. Can I have about 10 minutes of your time?

  4. If "Yes"*

    1. If "No"

    2. 1. Where are you sleeping tonight? (DO NOT READ CATEGORIES. SELECT ONLY ONE CATEGORY)

    3. For the following, GO TO question 2.

    4. For the following, STOP

    5. 2. Did another volunteer or survey worker already ask you these same questions about where you are staying tonight?

    6. Select one

    7. 3. Including yourself, how many adults and children are there in your household, who are sleeping in the same location with you tonight?

    8. 4. What are your name/ initials? (ALL PERSONS IN HOUSEHOLD) -----[IF RESPONDENT SAYS DON'T KNOW OR REFUSED, WRITE OUT "DON'T KNOW" OR "REFUSED"].

    9. 5. What is the relationship to Person One?

    10. 6. How old are you / DOB? (IF HESITANT< ASK: Are you ....?)

    11. 6. How old are you / DOB? (IF HESITANT, ASK: Are you ..... ?)

    12. OR

    13. OR

    14. OR

    15. OR

    16. OR

    17. 7. What is your gender?

    18. Person 1

    19. Person 2

    20. Person 3

    21. Person 4

    22. Person 5

    23. 8. Are you Hispanic or Latino?

    24. Person 1

    25. Person 2

    26. Person 3

    27. Person 4

    28. Person 5

    29. 9. What is your race? You can select one or more races. [READ CATEGORIES, DO NOT READ "Other, specify "]

    30. Person 1

    31. Person 2

    32. Filler

    33. Person 3

    34. Person 4

    35. Person 5

    36. 10. Have you served in the United States Armed Forces (Army, Navy, Air Force, Marine Corps or Coast Guard)?

    37. Person 1

    38. Person 2

    39. Person 3

    40. Person 4

    41. Person 5

    42. 11. Is this the first time you have been homeless?

    43. Person 1

    44. Person 2

    45. Person 3

    46. Person 4

    47. Person 5

    48. 12. How long have you been homeless THIS TIME? Only include time spent staying in shelters and/or on the streets. ---------------- [FOR EACH PERSON, ENTER A NUMBER AND ONE OF THE FOLLOWING: DAYS / WEEKS / MONTHS / YEARS, OR ENTER DK / REF].

    49. 13. [IF Q11 = YES (FIRST TIME HOMELESS), THEN SKIP TO Q14]. Including this time, how many separate times have you stayed in shelters or on the streets in the past 3 years (that is, since January 2014?) Was it 4 or more times, or was it less than 4 times?

    50. Person 1

    51. Person 2

    52. Person 3

    53. Person 4

    54. Person 5

    55. 13a. In total, how long did you stay in shelters or on the streets for those times? ---------------------------- [FOR EACH PERSON, ENTER A NUMBER AND ONE OF THE FOLLOWING: DAYS / WEEKS / MONTHS / YEARS, OR ENTER DK / REF].

    56. [ONLY ASK QUESTIONS Q14 - Q18 TO PERSONS AGE 18 AND OLDER]

    57. 14. Please tell me whether any of these situations apply to you.

    58. 14a. Do you / does Person [2-5] drink alcohol?

    59. Person 1

    60. Person 2

    61. Person 3

    62. Person 4

    63. Person 5

    64. 14b. Do you / does Person [2-5] use illegal drugs? This includes prescription drugs that were not prescribed for you.

    65. Person 1

    66. Person 2

    67. Person 3

    68. Person 4

    69. Person 5

    70. 14c. Do you / does Person [2-5] have any ongoing health problems or medical conditions such as diabetes, cancer, heart disease?

    71. Person 1

    72. Person 2

    73. Person 3

    74. Person 4

    75. Person 5

    76. 14d. Do you / does Person [2-5] have psychiatric or emotional conditions such as depression or schizophrenia?

    77. Person 1

    78. Person 2

    79. Person 3

    80. Person 4

    81. Person 5

    82. 14e. Do you / does Person [2-5] have a physical disability?

    83. Person 1

    84. Person 2

    85. Person 3

    86. Person 4

    87. Person 5

    88. [IF ONE OR MORE ANSWERS FROM Q14a - Q14e = YES, THEN ASK Q14f. IF PERSON HAS NONE OF THESE HEALTH ISSUES, THEN SKIP TO Q15.]

    89. 14f. Do any of the situations we just discussed keep you from holding a job or living in stable housing?

    90. Person 1

    91. Person 2

    92. Person 3

    93. Person 4

    94. Person 5

    95. 14g. [IF Q14f = YES, THEN ASK Q14g. IF NOT, SKIP TO Q15]. ---------------- Which ones keep you from holding a job or living in stable housing?

    96. Person 1

    97. Person 2

    98. Person 3

    99. Person 4

    100. Person 5

    101. 15. Do you / does Person [2-5] have AIDS or an HIV-related illness?

    102. Person 1

    103. Person 2

    104. Person 3

    105. Person 4

    106. Person 5

    107. 16. Do you / does Person [2-5] receive any disability benefits such as Social Security Income, Social Security Disability Income or Veteran's Disability Benefits?

    108. Person 1

    109. Person 2

    110. Person 3

    111. Person 4

    112. Person 5

    113. 17. Are you a domestic violence survivor or victim?

    114. Person 1

    115. Person 2

    116. Person 3

    117. Person 4

    118. Person 5

    119. Thanks for taking the survey!

    120. [IF MORE ADULTS IN HH GO BACK TO Q4 TO COMPLETE COLUMNS FOR PERSONS 2-5].

    121. Would you like someone to follow up with you about services?

    122. Services:

    123. Services:

    124. Filler

    125. Leave This Blank:

    126. This field is not part of the form submission.