Fort Walton Beach Council agenda — 2-11-14--regular — reading text

Opportunity, Inc ATTACHMENTS: 1 - 28 -14 Opportunity Inc Survey Form ( PDF) SIGNATURE BLOCK: Carole Jones Completed 01/ 21/ 2014 8: 35 AM Carole Jones Completed 01/ 21/ 2014 8: 35 AM City Manager Completed 01/ 23/ 2014 2: 39 PM City Council Pending Page 1 of 1  2014 Point In Time Survey OPPORTUNITY, INC. flLlswaa N' al li•xualrr C: suwum oCl' xre Name of Agency: Name of Interviewer: Location of Interveiw Are you homeless? ( if no end survey) Y N y N Did another survey worker already survey you? c Including yourself how many in household? First Name c Last Name Ag 0 Social Security or Last Four ofSS Number CL CL Month of Birth O Day of Birth Year of Birth c 0 Gender M I F JTGIVI JTGF M c Race ( Primary/ Secondary) a Ethnicity ydL y N a Are your Hispanic or Latino? M O Where were you sleeping last night'! ( Please V) v N E L Street or Sidewalk 0 U. VehicleVehicle ( ( Car,Car, van,van, RV,RV, Truck)Truck) d Park N Abandon Building U Bus Station c Under Bridge / Over pass r WoodsWoods oror outdooroutdoor encampmentencampment 3 t= 0 0. Household Type (Please CL O Single 00 N Single with Children (how many children) r MarriedMarried c m Married with Children (how many children) E r to Prior Episodes of Homelessness in last 3 ears number Q of separate times homeless. ( Please j No Prior Expisosed of Homelessness One Time 2 - 3 Times 4 or more times Length Prior Okaloosa Walton CDC Point in Time Survey - Shelley Poirrier Executive Director Opportunity INC. Length of Current Homeless Episode ( Please ) 1 Week or Less More than one week, less than one month 1 to 3 months More than 3 months, less than 12 months 1 year or longer Data Element Cause of Homelessness ( Please ) c Employment/ Financial Reason Housing Issues - Forced to relocate c Medical / Disability Problems t 0 CL Family Problems CL Domestic Violence O Natural / other Disaster M r- Recent Immigration 0 c Data Element Length of Stay in the County Prior to m Becoming Homeless ( Please 2) a M 1 week or less 0ti N More than 1 week, less than 1 month 1 to 3 months More than 3 months, less than 12 months 1 year or longer Military History Ej E 0 LL m c Are You A Veteran? y N c 3 Spouse of Veteran? y N t_ 0 Have you served in the United States Armed Forces? Y N CL CL Were you ever called into active duty as a member of the O v National Guard or as a Reservist? y N Have you ever received health care or benefits from a N ao Veteran' s Administration medical center? Y N c m E s R r Q Okaloosa Walton COC Point in Time Survey - Shelley Poirrier Executive Director Opportunity INC.  Type of Disabling Condition Physical Y N Mental Health Y N Developmental Y N Drug or Alcohol Addiction Y N HIV /AIDS Y N Any ongoing health problems or medical conditions such as diabetes, cancer, heart disease? Y N Post -traumatic stress disorder or PTSD? Y N V E Psychiatric or emotional conditions such as depression or schizophrenia? Y N c Physical disability? Y N 0 Received special education ( or special ed) services for CL CL more than 6 months? Y N O Had a traumatic injury to your /their brain from a bump, M c blow, or wound to the head? Y N 0 Do you use illegal drugs? This includes prescription drugs c that were not prescribed for you. Y N mv! Have you ever been treated for alcohol abuse? Y N a Do any of the situations we just discussed keep you from holding a job or living in stable housing? Y N M 0 Do you receive any disability Y N E