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____________________________
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