appendix b - United Way of the Plains
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APPENDIX B 2009 Kansas Point-in-Time Survey Forms English (side one & side two) English (side two only with county specific questions) Johnson, Saline, Sedgwick & Wyandotte Counties Spanish (side one & two) Abbreviated Domestic Violence Printout of Computer Survey English (side one only due to same supplemental questions on all side two forms) Spanish (side one only due to same supplemental questions on all side two forms) Allen County Everybody Counts! Survey (Kansas 2009) 001 Rev—12/9/08 Person collecting the survey ____________________________ Collected through which (Please check one): Street* Shelter/Site* _________________ You can make a difference! Please fill out this survey so the community can identify what types of housing and services are necessary to better meet your needs. Your answers are confidential. Results will be reported as a group only—not identified by individual responses. Please complete only one form for the 2009 count. 1. Have you completed this survey in 2009? **If YES, stop and do not complete a survey. If NO, please continue.** First letter of your First name ____ First letter of your Middle name ____ First letter of your Last name ____ Your date of birth: Month___________ 2. Have you ever been in the military? Day_____ Year__________ Yes 9a.If you answered that you stayed in emergency shelter, DV shelter, youth shelter or hotel/motel paid for by others, or other sheltered living situation in #4 or #5b, which type of program would be more helpful to end your homelessness? **PLEASE ONLY CHECK ONE OPTION** Transitional Housing Permanent Supportive Housing (housing with access to services) No 3. Did you stay at a house, apartment, mobile home, or hotel/motel overnight on January 27th? Yes No No Response **If Yes, go to #3a; if No or No Response, go to #4** 3a. If Yes, did you personally pay to stay there? Yes No No Response **If Yes, please stop survey; if No or No Response go to #4** 10. How long have you been without a place to stay this time? less than 30 days more than 30 days but less than a year a year or more 4. Did you stay overnight at any of the following on January 27th? In a car, or on the street, under a bridge, abandoned building, public building, traveling by bus, camping out, etc? Emergency Shelter Youth shelter Domestic Violence shelter 11. Have you been without a place to stay before? Yes No 11a. If Yes, in the last three years, how many times have you been without a place to stay before this time? ___________ 12. Do you think you have or have been told you have: **CHECK ALL THAT APPLY** Serious mental illness Chronic physical illness or disability Diagnosable substance use disorder Developmental disability HIV/AIDS Other______________________________________________ None of these Transitional housing (for homeless persons) Hotel/Motel paid for by others/vouchers Halfway house without paying. * With family or friends without paying. * *Have you been told you have to leave within a week? Yes No Don’t know **If any of the above boxes are checked, please go to #6** None of these **If “None of these” is checked, go to #5** 5. Did you stay overnight at any of the following on January 27th? Prison/Youth Correctional Psychiatric hospital facility Jail/Juvenile detention facility Medical hospital Substance Abuse treatment center **If any of the above boxes are checked, go to #5a then #5b** Other_____________________ None of these. If None, go to#6 5a. Did you stay there for 30 days or more? Yes No AND 5b. If you stayed overnight in a facility noted in #5 on January 27th, where do you plan to stay tonight? In a car, or on the street, under a bridge, abandoned building, public building, traveling by bus, camping out, etc? Emergency Shelter Youth shelter Domestic Violence shelter Transitional housing (for homeless persons) Hotel/Motel paid for by others/vouchers Halfway house without paying. * With family or friends without paying. * *Have you been told you have to leave within a week? Yes No Don’t know Other_______________________________________________ None of these 6. In which county/state did you stay last night?___________________ 7. Is your current situation the result of domestic violence? Yes 8. What is your gender? Male Female Transgender 9. If you answered that you stayed in a car, or in the street, under a bridge, abandoned building, public building or other unsheltered living situation in #4 or #5b, which type of program would be most helpful to end your homelessness? **PLEASE ONLY CHECK ONE OPTION** Emergency Shelter Transitional Housing Permanent Supportive Housing (housing with access to services) No 13. What is your racial and ethnic background? Hispanic Non-Hispanic Asian Black/African-American Native American/Alaskan Native White Multi-racial Other ____________________________________________ 14. Which of the following best describes your family/household right now? *Do not include family members who do not currently live with you.* Single individual-If checked, please go to #16 Two adult family with NO children Two adult family with children (# in Household ________) Single adult with children (# in Household ________) Other_________________________________________ 15. Please complete the following for family members who are with you and have no permanent place to live. PersonSpouse/ GrandOther F-M-L DOB partner Child child relative FML = First, Middle, Last initials Kansas 2009 Everybody Counts! Survey Supplemental Questions Rev 11-24-08 15. Are you or anyone else in your family receiving ANY of the following government benefits? SSI/SSDI VA Pension/Benefits Temporary Assistance for Families Medicaid/Medicare Food Stamps Other government benefit None of these 16. In the past month, which of the following services did you or anyone in your family need? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help finding Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Rent or utility assistance None of these Medical care Other service ____________________________ 17. In the past month, which of the following services did you or anyone in your family receive? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help finding Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Rent or utility assistance Medical care None of these County Specific Questions Other service ____________________________ Rev 12-22-08 Kansas 2009 Everybody Counts! Survey Supplemental Questions 16. Are you or anyone else in your family/household receiving ANY of the following government benefits? SSI/SSDI VA Pension/Benefits Temporary Assistance for Families Medicaid/Medicare Food Stamps Other government benefit None of these 17. In the past month, which of the following services did you or anyone in your family/household need? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these 18. In the past month, which of the following services did you or anyone in your family/household receive? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these Johnson County Questions 19. Please check the reasons why you became homeless CHECK ALL THAT APPLY Unemployment Low wages Foreclosure Unable to pay utilities Illness or disability – of family member or self Alcohol or substance abuse Domestic violence Child abuse – for youth on their own Public assistance limitations/sanctions Bad credit history Fire/flood/natural disaster Family rejection Other ___________________________________________________ 20. Are you or someone in your immediate household currently employed or have a job? Yes Unable to pay rent/mortgage Eviction Aged out of foster care system Discharge from prison/jail Reasons related to discrimination Moved to seek work No Kansas 2009 Everybody Counts! Survey Supplemental Questions Rev 12-22-08 16. Are you or anyone else in your family/household receiving ANY of the following government benefits? SSI/SSDI VA Pension/Benefits Temporary Assistance for Families Medicaid/Medicare Food Stamps Other government benefit None of these 17. In the past month, which of the following services did you or anyone in your family/household need? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these 18. In the past month, which of the following services did you or anyone in your family/household receive? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these Saline County Questions 19. How long have you been homeless in Saline County or the Salina area? ______________________ 20. Have you ever lived or stayed in one or more of the following Saline County Homeless Shelters? Ashby House Domestic Violence Association of Central Kansas (DVACK) Salina Rescue Mission Have not stayed in any of these 21. Has someone ever paid for you to live or stay in a Saline County hotel or motel? Yes No Kansas 2009 Everybody Counts! Survey Supplemental Questions Rev 1-16-09 16. Are you or anyone else in your family/household receiving ANY of the following government benefits? SSI/SSDI VA Pension/Benefits Temporary Assistance for Families Medicaid/Medicare Food Stamps Other government benefit None of these 17. In the past month, which of the following services did you or anyone in your family/household need? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these 18. In the past month, which of the following services did you or anyone in your family/household receive? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these Sedgwick County Questions 19. In the past month, what services did you not receive for which you or anyone in your family/household applied? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these 20. If you checked that you applied for a service but did not receive the service, please indicate the service and the reason(s) you did not receive the service(s)? CHECK ALL THAT APPLY Service: Did not meet eligibility guidelines Had already received the service within the last ______________ months/years Have been placed on a waiting list for the service The service was no longer available, such as funds available for rent assistance Other reason ____________________________ Service: Did not meet eligibility guidelines Had already received the service within the last ______________ months/years Have been placed on a waiting list for the service The service was no longer available, such as funds available for rent assistance Other reason ____________________________ Service: Did not meet eligibility guidelines Had already received the service within the last ______________ months/years Have been placed on a waiting list for the service The service was no longer available, such as funds available for rent assistance Other reason ____________________________ Kansas 2009 Everybody Counts! Survey Supplemental Questions Rev 12-22-08 16. Are you or anyone else in your family/household receiving ANY of the following government benefits? SSI/SSDI VA Pension/Benefits Temporary Assistance for Families Medicaid/Medicare Food Stamps Other government benefit None of these 17. In the past month, which of the following services did you or anyone in your family/household need? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these 18. In the past month, which of the following services did you or anyone in your family/household receive? CHECK ALL THAT APPLY Help finding work/employment Transportation/ bus passes Alcohol or drug abuse treatment assistance Help applying for Section 8 or other Help getting government benefits Help getting a Kansas ID or driver’s license permanent housing Emergency shelter Dental care Mental Health care Food Child care Other service ____________________________ Rent or utility assistance Medical care None of these Wyandotte County Questions 19. Did you share the house, apartment, mobile home, or hotel/motel in which you stayed overnight on January 27? Yes No If Yes, go to #19a. If No, go to #20 19a. How long do you plan on sleeping at this residence? Less than one week One week to one month One to three months Indefinitely 19b. Please check all that apply regarding your current living situation. My current housing is temporary I am currently looking for another place I could be kicked out at any time I stay at a different place each day/week I share my place with a number of people (please indicate number)__________ 20. Please list the reasons why you became homeless and/or that prevent you from finding a place of your own(check all that apply) Unemployment Family rejection Welfare assistance sanctions Inability to pay deposit/rent/mortgage Like staying where I am free Welfare time limits Previous evictions Moved to seek work Reasons related to sexual orientation Illness – self or family member Low wages Fire/flood/natural disaster Don’t like/can’t get shelter/transitional Mental disabilities (illness) Inability to pay utilities housing. Filed for disability but not approved Criminal record/discharge from jail/prison Welfare payments not adequate Alcohol or substance abuse Child abuse(for youth on their own) Bad credit history Physical disabilities (illness) 21. Do you lack transportation? Yes No 22. What do you need public transportation to do? Get to job or for job search Get to school Search for housing Get to grocery store/shopping Other_____________________________ Encuesta ¡Todos Cuentan! Condado de ________ (Kansas 2009) Administrador de la encuesta________________________________ ¿Donde se administro la encuesta? (por favor seleccione una opción): En la calle En un albergue/Sitio______________________ _____________________________________________________________________________________________________________________________________________ ¡Usted puede hacer una diferencia! Por favor llene este cuestionario para que nuestra comunidad pueda identificar que tipo de alojamiento y que tipo de servicios son necesarios para servirle mejor. Sus respuestas se mantendrán en confidencia. Los resultados de esta encuesta se presentaran solo en resumen –no se identificaran respuestas individuales. Por favor, llene solo un cuestionario para la encuesta del año 2009. 1. ¿Ha llenado usted este cuestionario en el año 2009? Si Si ya lo llenó, por favor pare. Si no, por favor continúe. No Primera letra de su Primer nombre___ Primera letra de su Segundo nombre___ Primera letra de su Apellido___ Su fecha de nacimiento: Mes___________ Día_______ Año________ 2. ¿Ha servido usted en el ejército de los Estados Unidos? Si No 3. ¿Durmió usted en una casa, departamento, casa móvil, o en un hotel/motel en la noche del 27 de Enero? Si No No respuesta Si es Si, vaya a la pregunta #3a, Si es No o No Respuesta, vaya a la #4 3a. ¿Pagó usted con su propio dinero para quedarse ahí? Si No No respuesta Si es Si, por favor pare. Si es No o No Respuesta vaya a la #4 4. ¿Durmió usted en uno de los siguientes lugares en la noche del 27 de Enero? En un coche, en la calle, bajo de un puente, en edificio abandonado, en edificio publico, viajando por autobús, en tienda de campaña, etc. Albergue de Emergencia Albergue para Jóvenes Albergue para victimas de Violencia Domestica/Intrafamiliar Hogar De Paso (para personas sin hogar) Hotel/Motel pagado por otras personas o por vale/cupón Centro de Rehabilitación sin tener que pagar. * Con parientes o con amigos sin tener que pagar. *¿Le han dicho a usted que se vaya de ahí dentro de una semana? Si No No Se **Si se marcó alguna de estas opciones, por favor vaya a la #6** Ninguno de estos lugares **Si se marcó esta opción, vaya a la #5** 5. ¿Durmió usted en uno de los siguientes lugares en la noche del 27 de Enero? Prisión o Centro Correccional Juvenil Hospital Psiquiátrico Cárcel o Centro de Detención Juvenil Hospital Medico Centro de Tratamiento para el Alcoholismo o la Drogadicción ** Si marco una de estas opciones, vaya al #5a, luego al #5b** Otro____________________________ Ninguno. Vaya a la #6 5a. ¿Estuvo usted ahí por más de 30 días? Si No Y 5b. Si estuvo usted en uno de los lugares de la pregunta #5 en Enero 27 ¿En donde va a dormir esta noche? En un coche, en la calle, bajo de un puente, en un edificio abandonado, en un edificio publico, viajando por autobús, en tienda de campaña, etc. Albergue de Emergencia Albergue para Jóvenes Albergue para victimas de Violencia Domestica/Intrafamiliar Hogar De Paso (para personas sin hogar) Hotel/Motel pagado por otras personas o por vale/cupón Centro de Rehabilitación sin tener que pagar. * Con parientes o con amigos sin tener que pagar. *¿Le han dicho a usted que se valla de ahí dentro de una semana? Si No No Se Otro lugar______________________________________ Ninguno de estos lugares 9. Si en las preguntas #4 y #5b, usted contesto que durmió en un coche, en la calle, bajo un puente, en un edificio abandonado, en un edificio público, o en cualquier otro lugar sin albergue, ¿Qué tipo de programa social seria mas beneficial para acabar con su situación sin hogar? **POR FAVOR SELECCIONE SOLO UNA OPCION** Albergue de Emergencia Hogar De Paso Vivienda Asistida Permanente (vivienda con acceso a servicios) 9a. Si en las preguntas #4 y #5b usted contesto que durmió en un albergue de emergencia, un albergue para victimas de Violencia Domestica, un albergue juvenil, en hotel/motel pagado por otros, o en cualquier otro lugar con albergue, ¿Qué tipo de programa social seria mas beneficial para acabar con su situación sin hogar? **POR FAVOR SELECCIONE SOLO UNA OPCION** Hogar De Paso Vivienda Asistida Permanente (vivienda con acceso a servicios) 10. Esta vez, ¿Cuánto tiempo tiene usted sin hogar? Menos de 30 días Mas de 30 días, pero menos de un año Un año o mas 11. ¿Ha estado usted sin hogar anteriormente? Si No 11a. Si es Si: Sin contar esta vez, ¿Cuántas veces se ha encontrado usted sin hogar en los últimos 3 años?_______________________ 12. ¿Usted sufre o le ha dicho un profesionista medico que usted sufre de: **SELECCIONE TODAS LAS QUE SE APLIQUEN** Un trastorno mental serio Una enfermedad crónica o discapacidad Adicción diagnosticable Una discapacidad de desarrollo VIH/SIDA Otra cosa_________________________ Ninguna de estas 13. ¿Cuál es su raza y su etnia/etnicidad? Asiático Negro/Afro-Americano Indígena/Nativo de Alaska Blanco Multirracial Otro_________________________ Hispano No Hispano 14. ¿Cuál de las siguientes opciones describe a su familia? Por favor no incluya a miembros de su familia que no vivan con usted Individuo soltero(a) Familia de 2 adultos sin niños Familia de 2 adultos con niños (numero de niños________) Individuo soltero(a) con niños (numero de niños_________) Otro____________________________________________________ 15. Por favor, llene lo siguiente con información acerca de parientes que estén con usted y que no tengan hogar permanente. Persona- Fecha de Esposo(a)/ Hijo(a) Nieto(a) Otro P-S-A Nacimiento Compañero(a) 6. ¿En que Condado/Estado durmió usted anoche?_________________ 7. Esta situación en la que se encuentra usted, ¿Es resultado de Violencia Domestica? Si No 8. ¿Cuál es su sexo? Masculino Femenino Transexual P-S-A = Iniciales del Primer nombre, Segundo nombre, Apellido Encuesta ¡Todos Cuentan! Kansas 2009 Preguntas Adicionales Rev 12-22-08 16. ¿Recibe usted, o alguna otra persona en su familia cualquiera de los siguientes beneficios del gobierno? SSI/SSDI (Seguridad de Ingreso Suplementario/Seguro de Incapacidad del Seguro Social) Pensión/Beneficios de la Administración de Beneficios de Veteranos Asistencia Temporaria para Familias Medicaid/Medicare Estampillas Algún otro beneficio del gobierno____________________________ Ninguno de estos beneficios 17. En el mes pasado, ¿Necesito usted, o algún otro miembro de su familia, algunos de los siguientes servicios? SELECCIONE TODAS LAS OPCIONES QUE SE APLIQUEN Ayuda para encontrar trabajo/empleo Modo de transporte/boletos para el autobús Tratamiento para Alcoholismo o Drogadicción Ayuda para aplicar por sección 8 o Ayuda para obtener beneficios del gobierno. Ayuda para obtener una cartilla de identificación algún otro alojamiento permanente. de Kansas o una licencia para manejar. Albergue de Emergencia Atención dental Atención psiquiatrica (Salud Mental) Otro servicio ___________________________ Alimentos Guardería _________________________________________ Renta o ayuda para pagar servicios Atención medica públicos (electricidad, gas, etc.) Ninguno de estos servicios 18. En el mes pasado, ¿Recibió usted, o algún otro miembro de su familia, alguno de los siguientes servicios? SELECCIONE TODAS LAS OPCIONES QUE SE APLIQUEN Ayuda para encontrar trabajo/empleo Modo de transporte/boletos para el autobús Tratamiento para Alcoholismo o Drogadicción Ayuda para aplicar por sección 8 o Ayuda para obtener beneficios del gobierno. Ayuda para obtener una cartilla de identificación algún otro alojamiento permanente. de Kansas o una licencia para manejar. Albergue de Emergencia Atención dental Atención psiquiatrica (Salud Mental) Otro servicio ___________________________ Alimentos Guardería _________________________________________ Renta o ayuda para pagar servicios Atención medica públicos (electricidad, gas, etc.) Ninguno de estos servicios Preguntas Especificas del Condado Kansas 2009 Everybody Counts! Survey County: ____________________________ Collected through: Rev—1/23/09 Shelter You can make a difference! Please fill out this survey so the community can identify what types of housing and services are necessary to better meet your needs. Your answers are confidential. Results will be reported as a group only—not identified by individual responses. Please complete only one form for the 2009 count. Have you ever been in the military? Yes No Which type of program would be more helpful to end your homelessness? **PLEASE ONLY CHECK ONE OPTION** Transitional Housing Permanent Supportive Housing (housing with access to services) What is your gender? Male Female Transgender How long have you been without a place to stay this time? less than 30 days more than 30 days but less than a year a year or more Have you been without a place to stay before? Yes No If Yes, in the last three years, how many times have you been without a place to stay before this time? ___________ Which of the following best describes your family/household right now? *Do not include family members who do not currently live with you.* Single individual Two adult family with NO children Two adult family with children (# in Household ________) Single adult with children (# in Household ________) Other_________________________________ Encuesta ¡Todos Cuentan! (Kansas 2009) County/Condado de:________________________________ En un albergue _____________________________________________________________________________________________________________________________________________ ¡Usted puede hacer una diferencia! Por favor llene este cuestionario para que nuestra comunidad pueda identificar que tipo de alojamiento y que tipo de servicios son necesarios para servirle mejor. Sus respuestas se mantendrán en confidencia. Los resultados de esta encuesta se presentaran solo en resumen –no se identificaran respuestas individuales. Por favor, llene solo un cuestionario para la encuesta del año 2009. ¿Ha servido usted en el ejército de los Estados Unidos? Si No ¿Qué tipo de programa social seria mas beneficial para acabar con su situación sin hogar? POR FAVOR SELECCIONE SOLO UNA OPCION Hogar De Paso 8. ¿Cuál es su sexo? Vivienda Asistida Permanente (vivienda con acceso a Masculino Femenino Transexual Esta vez, ¿Cuánto tiempo tiene usted sin hogar? Menos de 30 días Mas de 30 días, pero menos de un año Un año o mas ¿Ha estado usted sin hogar anteriormente? Si No Si es Si: Sin contar esta vez, ¿Cuántas veces se ha encontrado usted sin hogar en los últimos 3 años? ______ ¿Cuál de las siguientes opciones describe a su familia? *Por favor no incluya a miembros de su familia que no vivan con usted* Individuo soltero(a) Familia de 2 adultos sin niños Familia de 2 adultos con niños (numero de niños________) Individuo soltero(a) con niños (numero de niños_________) Otro____________________________
