SURVEY Ontario Enumeration Component (can’t change questions) (not scored) What family members are staying with you tonight? [Indicate survey numbers for adults. Check all that apply] NONE ADULT - Survey #: ___ ___ ___ ___ PARTNER - Survey #: ___ ___ ___ ___ DECLINE TO ANSWER CHILD(REN)/DEPENDENT(S) 1 2 3 4 5 6 7 8 GENDER [indicate gender and age for each] AGE For the next questions, means any time when you have been without a secure place to live, “homelessness” including sleeping in shelters, on the streets, or living temporarily with others. ☐ Length ________________ days/weeks/months In total, how much time have you been ☐ Don’t Know homeless over the past year? ☐ Decline to answer [Best estimate] (PiT Q4) ☐ Number of times ___________ (includes this time) In total, how many different times have you ☐ Don’t Know experienced homelessness over the past ☐ Decline to answer year: [Best estimate] (use for TAY-VI-SPDAT Q3) (PiT Q5) ☐ Illness or medical condition What happened that caused you to lose ☐ Addiction or substance use your housing most recently? ☐ Job loss ☐ Unable to pay rent or mortgage [This is an open question with categories ☐ Evicted other reason (not financial) provided] ☐ Experienced abuse by: parent / guardian ☐ Experienced abuse by: spouse / partner ☐ Conflict with: parent / guardian (PiT Q13) ☐ Conflict with: spouse / partner ☐ Incarcerated (jail or prison) ☐ Hospitalization or treatment program ☐ Unsafe housing conditions
SURVEY Ontario Enumeration Component (can’t change questions) (not scored) What family members are staying with you tonight? [Indicate survey numbers for adults. Check all that apply] NONE PARTNER - Survey #: ___ ___ ___ ___ ADULT - Survey #: ___ ___ ___ ___ DECLINE TO ANSWER CHILD(REN)/DEPENDENT(S) 1 2 3 4 5 6 7 8 [indicate gender and age for each] GENDER AGE For the next questions, “homelessness” means any time when you have been without a secure place to live, including sleeping in shelters, on the streets, or living temporarily with others. In total, how much time have you been homeless over the past year? [Best estimate] (PiT Q4) ☐ Length ________________ days/weeks/months ☐ Don’t Know ☐ Decline to answer In total, how many different times have you experienced homelessness over the past year: [Best estimate] (PiT Q5) ☐ Number of times ___________ (includes this time) ☐ Don’t Know ☐ Decline to answer (use for TAY-VI-SPDAT Q3) What happened that caused you to lose your housing most recently? [This is an open question with categories provided] (PiT Q13) ☐ Illness or medical condition ☐ Addiction or substance use ☐ Job loss ☐ Unable to pay rent or mortgage ☐ Evicted other reason (not financial) ☐ Experienced abuse by: parent / guardian ☐ Experienced abuse by: spouse / partner ☐ Conflict with: parent / guardian ☐ Conflict with: spouse / partner ☐ Incarcerated (jail or prison) ☐ Hospitalization or treatment program ☐ Unsafe housing conditions
TAY-VI-SPDAT-V1-20K-RW-ONTARIO-ONLY-1.docx