2024 Unhoused Vulnerability Survey

Unhoused Vulnerability Survey
Interviewer Info*

NameAgency
Interviewer Email*
Today's Date*

MonthDayYear
Participant Name*

First NameLast Name
Alias/Nickname
Social Security Number
Please provide only last 4 digits
Are you a U.S. Military Veteran?*

YesNoClient doesn't knowClient prefers not to say
Date of birth*

MonthDayYear
Current Age*
Client Email
Phone Number
Race and Ethnicity*

American Indian, Alaska Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanHispanic/Latina/e/oMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhiteClient doesn't knowClient Prefers not to answerData not collected
If you identify as more than one race or ethnicity please select below.

American Indian, Alaska Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanHispanic/Latina/e/oMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhite
Gender*

Woman (Girl, if Child)Man (Boy, if Child)Culturally Specific Identity (e.g., Two-Spririt)TransgenderNon-BinaryQuestioningDifferent IdentityClient doesn't knowClient prefers not to answerData not collected
How many Adults are in your household*
Adults
How many Children are in your household*
Children (Age 0-17)
Emergency Contact Name

First NameLast Name
Relationship
Phone Number
1. Are you over the age of 55 or is anyone in your household over the age of 55?*

YesNo
2. Are you under the age of 24 or is anyone in your household under the age of 24*

YesNo
3. Do you have any source of income?*

YesNo
3a. If Yes, what is the 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?*

YesNo
4a. If yes, please click all that apply

Chronic Health ConditionDevelopmental DisorderMental/Behavioral Health IssuePhysical/Medical IssueHIV/AIDSAlcohol Use DisorderDrug/Substance Use DisorderClient prefers not to say
5. Where did you/your family sleep last night?*

Unsheltered - Streets / Place not meant for habitationEmergency Shelter, Motel/HotelFamily Member or Friend's HomeClient prefers not to answerData not collected
5a. If you said Unsheltered or Emergency Shelter, how long have you slept there?*

0-3 Months4-6 Months7-11 Months12+ MonthsClient prefers not to answerData not collected
5b. Did you feel unsafe or were you threatened with harm?*

YesNoClient prefers not to answerData not collected
6. Is this your 1st time being homeless?*

YesNoClient prefers not to answerData not collected
6a. If no, have many times have you been homeless in the last 3 years?:

2 times3 times4+ timesClient prefers not to answerData not collected or not applicable
7. Do you have past or pending charges, felonies, current fines or court issues ?*

YesNoClient prefers not to answer
Total Vulnerability Score
0-10 Vulnerable, 11-20 Highly Vulnerable, 21-29 Extremely Vulnerable
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.
Consent: By clicking "yes" you acknowledge that you have read and agree to the above "Clint Data Privacy Notice"

Yes
Date Signed

MonthDayYear
Date
Additional Notes:
Should be Empty: