Finally I’d like to ask you some questions to help us better understand homelessness and improve housing and support services. Male Female Transgender Other      What is your gender? Decline to State Have you ever served in the US Military? Yes No Refused    Korean War (June 1955)  Vietnam Era (August 1975)  Post Vietnam (May 1991)  Persian Gulf Era (August  If yes, which war/war era did you serve in? Afghanistan  Iraq  (Specify)  Refused  Honorable Other than Honorable   If yes, what was the character of your discharge? Bad Conduct Dishonorable Refused    Citizen Legal Resident Undocumented    What is your citizenship status? Refused  This city  This region  Where did you live prior to becoming homeless? Other part of the State  Somewhere else  (specify)___________________ Have you ever been in foster care? Yes No Refused    Have you ever been in jail? Yes No Refused    Have you ever been in prison? Yes No Refused    Do you have a permanent physical disability that limits your mobility? Yes No Refused    [i.e., wheelchair, amputation, unable to climb stairs]? Medicaid Medicare VA Private     What kind of health insurance do you have, if any? (check all that apply) Insurance None Other (specify): _________   On a regular day, where is it easiest to find you and what time of day is easiest to do so? Is there a phone number and/or email where someone can get in touch with you or leave you a message? Ok, now I’d like to take your picture. May I do so? Yes No Refused   
Finally I’d like to ask you some questions to help us better understand homelessness and improve housing and support services. What is your gender?  Male  Female  Transgender  Other  Decline to State Have you ever served in the US Military?  Yes  No  Refused If yes, which war/war era did you serve in?  Korean War (June 1955)  Vietnam Era (August 1975)  Post Vietnam (May 1991)  Persian Gulf Era (August  Afghanistan  Iraq  (Specify)  Refused If yes, what was the character of your discharge?  Honorable  Other than Honorable  Bad Conduct  Dishonorable  Refused What is your citizenship status?  Citizen  Legal Resident  Undocumented  Refused Where did you live prior to becoming homeless?  This city  This region  Other part of the State  Somewhere else (specify)___________________ Have you ever been in foster care?  Yes  No  Refused Have you ever been in jail?  Yes  No  Refused Have you ever been in prison?  Yes  No  Refused Do you have a permanent physical disability that limits your mobility? [i.e., wheelchair, amputation, unable to climb stairs]?  Yes  No  Refused What kind of health insurance do you have, if any? (check all that apply)  Medicaid  Medicare  VA  Private Insurance  None  Other (specify): _________ On a regular day, where is it easiest to find you and what time of day is easiest to do so? Is there a phone number and/or email where someone can get in touch with you or leave you a message? Ok, now I’d like to take your picture. May I do so?  Yes  No  Refused
Vi-Spdat-for-single-adults.docx