Atlanta Unsheltered PIT - 2022

Type of Encounter*

Interview Observational (I can't talk to this person.)

Where Did the Encounter Occur?

INFORMED CONSENT STATEMENT

READ TO EACH RESPONDENT

We are conducting a community-wide survey related to characteristics of people and their housing.

Participation is completely voluntary.
If you don't want to take the survey you don't have to answer any questions.
If you do the survey you can stop, you can change your mind or you can skip questions with no bad consequences.
Doing the survey or not doing the survey won't change what benefits you qualify for.
We will keep your participation in this survey confidential.
The agency responsible for the Point in Time count will make reports from the surveys.
The surveys don't get shared, then when the reports are done the surveys are deleted.
The reports are used for planning and do not include names.
If you agree to participate, I will read the questions to you and I will record your answers. It will take approximately 10 minutes to complete.

Have you already been interviewed for this year's Point-in-Time?*

Yes No

Name of Person Experiencing Homelessness*

First Name

Last Name

Observational Description*

Where are (were) you sleeping on the night of the count?*

On Streets/Homeless Camp Abandoned Property (not meant for habitation) Vehicle/Car Local Homeless Shelter Friends/Family (Doubled Up) My Apartment/House Hotel/Motel Jail/Institutional Setting

Other:

Name of Homeless Shelter:

Are (were) you with a household or by yourself?*

By Myself (Single) With Household (Family)

Are you Head of the Household?*

Yes No

All Household entries MUST begin with the Head of Household! Please locate Head of Household to begin entry.

Head of Household Check*

TOTAL # of Persons in Household?*

Includes Interviewee

All Households MUST consist of AT LEAST TWO PERSONS, otherwise the entry should be done as Single (By Myself).

You have EXCEEDED the maximum amount of PERSONS for this tool. Please break up household into groups and add additional notes on each group entry to indicate they be added together during analysis.

Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

Gender Numeric Output

Sums numeric values of selections

Error - Gender*

Race*

American Indian, Alaska Native, or Indigenous Asian or Asian American Black, African American, or African Hispanic/Latina/e/o Middle Eastern or North African Native Hawaiian or Pacific Islander White Unknown/Prefers not to answer

Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

Zip Code of Last Permanent Address:*

90 days or more

Zip Code

Refused/Don't Know

Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

Are (were) you fleeing Domestic Violence on night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency.

Have you ever served in the military?*

Yes No Refused/Don't Know

Additional Notes (if any):

Veteran Social Security Number

Social Security Number

Refused/Don't Know

Veteran Date of Birth

Date of Birth

Refused/Don't Know

Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

Veteran Phone #

Veteran Email

Other Veteran Contact Info

IF YOU COMPLETE THE VETERANS SUPPLEMENTAL SECTION THIS ENTIRE SURVEY WILL BE SHARED WITH THE VETERANS ADMINISTRATION

IF YOU AND/OR YOUR HOUSEHOLD ARE WILLING TO PARTICIPATE, PLEASE SIGN BELOW. THANK YOU FOR YOUR HELP.

Signature of Respondent*

[clear]

Use your mouse or finger to draw your signature above

CHECK ONLY IF RESPONDENT SIGNATURE IS NOT ABLE TO BE OBTAINED FOR THE INFORMED CONSENT STATEMENT.

Respondent Refused Signature (No Data Shared with Federal Partners) Entering Data From Paper Survey

I READ THE CONSENT STATEMENT TO THE RESPONDENT AND TO THE BEST OF KNOWLEDGE IT WAS UNDERSTOOD, AND THE RESPONDENT HAS AGREED TO PARTICIPATE.

Observational Entry Type*

Live Observation Entering Data From Paper Survey

SURVEYOR PRINTED NAME*

First Name

Last Name

SURVEYOR AGENCY AFFILIATION (if any)

(1) Name of Household Member*

First Name

Last Name

(1) Observational Description*

(1) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(1) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(1) Gender*

Male Female Transgender A gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender) Questioning Refused/Don't Know

Select all that apply

(1) Gender Numeric Output

Sums numeric values of selections

(1) Error - Gender*

(1) Race*

(1) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(1) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(1) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(1) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?

Fewer than 12 months 12 months or more Refused/Don't Know

(1) Zip Code of Last Permanent Address:*

90 days or more

(1) Zip Code

Refused/Don't Know

(1) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(1) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(1) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(1) Have you ever served in the military?*

Yes No Refused/Don't Know

(1) Veteran Social Security Number

(1) Social Security Number

Refused/Don't Know

(1) Veteran Date of Birth

(1) Date of Birth

Refused/Don't Know

(1) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(1) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(1) Veteran Phone #

(1) Veteran Email

(1) Other Veteran Contact Info

(2) Name of Household Member*

First Name

Last Name

(2) Observational Description*

(2) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(2) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(2) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(2) Gender Numeric Output

Sums numeric values of selections

(2) Error - Gender*

(2) Race*

(2) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(2) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(2) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(2) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(2) Zip Code of Last Permanent Address:*

90 days or more

(2) Zip Code

Refused/Don't Know

(2) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(2) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(2) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(2) Have you ever served in the military?*

Yes No Refused/Don't Know

(2) Veteran Social Security Number

(2) Social Security Number

Refused/Don't Know

(2) Veteran Date of Birth

(2) Date of Birth

Refused/Don't Know

(2) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(2) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(2) Veteran Phone #

(2) Veteran Email

(2) Other Veteran Contact Info

(3) Name of Household Member*

First Name

Last Name

(3) Observational Description*

(3) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(3) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(3) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(3) Gender Numeric Output

Sums numeric values of selections

(3) Error - Gender*

(3) Race*

(3) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(3) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(3) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(3) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(3) Zip Code of Last Permanent Address:*

90 days or more

(3) Zip Code

Refused/Don't Know

(3) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(3) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(3) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(3) Have you ever served in the military?*

Yes No Refused/Don't Know

(3) Veteran Social Security Number

(3) Social Security Number

Refused/Don't Know

(3) Veteran Date of Birth

(3) Date of Birth

Refused/Don't Know

(3) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(3) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(3) Veteran Phone #

(3) Veteran Email

(3) Other Veteran Contact Info

(4) Name of Household Member*

First Name

Last Name

(4) Observational Description*

(4) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(4) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(4) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(4) Gender Numeric Output

Sums numeric values of selections

(4) Error - Gender*

(4) Race*

(4) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(4) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(4) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(4) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(4) Zip Code of Last Permanent Address:*

90 days or more

(4) Zip Code

Refused/Don't Know

(4) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(4) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(4) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(4) Have you ever served in the military?*

Yes No Refused/Don't Know

(4) Veteran Social Security Number

(4) Social Security Number

Refused/Don't Know

(4) Veteran Date of Birth

(4) Date of Birth

Refused/Don't Know

(4) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(4) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(4) Veteran Phone #

(4) Veteran Email

(4) Other Veteran Contact Info

(5) Name of Household Member*

First Name

Last Name

(5) Observational Description*

(5) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(5) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(5) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(5) Gender Numeric Output

Sums numeric values of selections

(5) Error - Gender*

(5) Race*

(5) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(5) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(5) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(5) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(5) Zip Code of Last Permanent Address:*

90 days or more

(5) Zip Code

Refused/Don't Know

(5) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(5) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(5) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(5) Have you ever served in the military?*

Yes No Refused/Don't Know

(5) Veteran Social Security Number

(5) Social Security Number

Refused/Don't Know

(5) Veteran Date of Birth

(5) Date of Birth

Refused/Don't Know

(5) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(5) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(5) Veteran Phone #

(5) Veteran Email

(5) Other Veteran Contact Info

(6) Name of Household Member*

First Name

Last Name

(6) Observational Description*

(6) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(6) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(6) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(6) Gender Numeric Output

Sums numeric values of selections

(6) Error - Gender*

(6) Race*

(6) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(6) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(6) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(6) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(6) Zip Code of Last Permanent Address:*

90 days or more

(6) Zip Code

Refused/Don't Know

(6) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(6) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(6) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(6) Have you ever served in the military?*

Yes No Refused/Don't Know

(6) Veteran Social Security Number

(6) Social Security Number

Refused/Don't Know

(6) Veteran Date of Birth

(6) Date of Birth

Refused/Don't Know

(6) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(6) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(6) Veteran Phone #

(6) Veteran Email

(6) Other Veteran Contact Info

(7) Name of Household Member*

First Name

Last Name

(7) Observational Description*

(7) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(7) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(7) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(7) Gender Numeric Output

Sums numeric values of selections

(7) Error - Gender*

(7) Race*

(7) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(7) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(7) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(7) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(7) Zip Code of Last Permanent Address:*

90 days or more

(7) Zip Code

Refused/Don't Know

(7) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(7) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(7) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(7) Have you ever served in the military?*

Yes No Refused/Don't Know

(7) Veteran Social Security Number

(7) Social Security Number

Refused/Don't Know

(7) Veteran Date of Birth

(7) Date of Birth

Refused/Don't Know

(7) Branch of Service

Air Force Army Navy Marine Corps Coast Guard Refused/Don't Know

(7) National Guard/Reserve

Yes No Refused/Don't Know

Veteran Contact information:
(Optional)

(7) Veteran Phone #

(7) Veteran Email

(7) Other Veteran Contact Info

(8) Name of Household Member*

First Name

Last Name

(8) Observational Description*

(8) Is this household member a Dependent Child?*

Yes No Refused/Don't Know

(8) Age Category*

Under 18 18-24 25 and Over Refused/Don't Know

(8) Gender*

Woman (Girl if a child) Man (Boy if a child) Culturally Specific Identity (e.g., Two-Spirit) Transgender Non-Binary Questioning Different Identity Unknown/Prefers not to answer

Select all that apply

(8) Gender Numeric Output

Sums numeric values of selections

(8) Error - Gender*

(8) Race*

(8) Ethnicity*

Hispanic/Latin(a)(o)(x) Non-Hispanic/Non-Latin(a)(o)(x) Refused/Don't Know

(8) How long have you been living on the streets or in emergency shelters?*

Less than a year A year or more Refused/Don't Know

(8) Number of times you have been homeless (on the streets or in emergency shelters) in the past 3 years?*

1 (this is the first time) 2-3 times 4 or more times Refused/Don't Know

(8) Total number of months you spent at least one day homeless (on the streets or in emergency shelters) in the past 3 years?*

Fewer than 12 months 12 months or more Refused/Don't Know

(8) Zip Code of Last Permanent Address:*

90 days or more

(8) Zip Code

Refused/Don't Know

(8) Do you have a disability? (MARK ALL THAT APPLY)*

NONE Drug Abuse Alcohol Abuse Mental Health Physical Developmental Chronic Health Condition HIV/AIDS Refused/Don't know

(8) Have you ever been a victim of domestic violence?*

Yes No Refused/Don't Know

(8) Are (were) you fleeing Domestic Violence on the night of the count?*

Yes No Refused/Don't Know

Immediately offer to call 911 or local Domestic Violence Agency. (State of Iowa DV Helpline: 1-800-770-1650)

(8) Have you ever served in the military?*

Yes No Refused/Don't Know

ATLANTA UNSHELTERED PIT SURVEY - 2022

VETERAN SUPPLEMENTAL SECTION

INFORMED CONSENT SIGNATURE

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD

HOUSEHOLD MEMBERS INFORMATION

VETERAN SUPPLEMENTAL SECTION - HOUSEHOLD