2024 Unhoused Vulnerability Survey

  • Unhoused Vulnerability Survey

  • Today's Date*
     - -
  • Are you a U.S. Military Veteran?*
  • Date of birth*
     - -
  • Format: (000) 000-0000.
  • Are you currently pregnant?*
  • Race and Ethnicity*
  • If you identify as more than one race or ethnicity, please select below
  • Gender*
  • Format: (000) 000-0000.
  • 1. Is any other member of your household over the age of 55?*
  • 2. Is any other member of your household 24 years old or younger?*
  • 3. Do you have any source of income?*
  • 4. Do you or a member of your household have a disabling condition like a physical, mental, emotional, developmental, HIV/AIDS, or substance use disorder that significantly impairs your ability to perform daily activities?*
  • 4a. If yes, please click all that apply
  • 5. Where did you/your family sleep last night?*
  • 5a. If you said Unsheltered or Emergency Shelter, how long have you slept there?*
  • 5b. Did you feel unsafe or were you threatened with harm?*
  • 6. Is this your 1st time being homeless?*
  • 6a. If no, have many times have you been homeless in the last 3 years?:
  • 7. Do you have past or pending charges, felonies, current fines or court issues ?*

  • CLIENT DATA PRIVACY NOTICE

    This agency collects personal information from the clients that we serve and enters this information into HMIS, the Homeless Management Information System. HMIS is a web-based information management system used by many social service agencies across the state of Arkansas. For many agencies in Arkansas, the use of a homeless management information system (HMIS) is a requirement of the U.S. Department of Housing and Urban Development (HUD) in order to receive funding to provide services for homeless and near homeless individuals and their families. This requirement was established in order to get a more accurate count of individuals and families who are homeless. The HMIS system also allows our agency to more effectively serve our clients. We only collect information that we consider to be appropriate. The collection and use of all personal information is guided by strict standards of confidentiality and security. Your data may be shared with participating service providers to enable referral process. You do not have to provide your personal information, but without your information, we may not be able to provide services to you. You have a right to review the personal information that we have about you. If you find any mistakes, you can ask us to correct them. Please tell our staff if you have any questions.

  • Date Signed
     - -
  • Should be Empty: