Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Living Situation1. What is your living situation today? I have a steady place to live I have a place to live today, but I am worried about losing it in the future I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park) 2. Think about the place you live. Do you have problems with any of the following?Choose all that apply Pests such as bugs, ants, or mice Mold Lead paint or pipes Lack of heat Oven or stove not working Smoke detectors missing or not working Water leaks None of the above FoodSome people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.3. Within the past 12 months, you worried that your food would run out before you got money to buy more. Often true Sometimes true Never true 4. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more. Often true Sometimes true Never true Transportation5. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? Yes No Utilities6. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home? Yes No Already shut off SafetyBecause violence and abuse happens to a lot of people and affects their health we are asking the following questions.7. How often does anyone, including family and friends, physically hurt you? Never Rarely Sometimes Fairly often Frequently 8. How often does anyone, including family and friends, insult or talk down to you? Never Rarely Sometimes Fairly often Frequently 9. How often does anyone, including family and friends, threaten you with harm? Never Rarely Sometimes Fairly often Frequently 10. How often does anyone, including family and friends, scream or curse at you? Never Rarely Sometimes Fairly often Frequently
