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NC-516 Point-in-Time Count

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Is this survey Observational Only or In-Person Interaction?
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Thank you for your time, That is the only question I have for you today.
Is this survey for an Individual or a Family?
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Which best describes your family/household staying with you tonight?
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Please remember to record a survey for each person in a family unit.

Demographics

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What is your date of birth?
For example: 3 27 2007
must be a month (1-12)
must be a day of the month (1-31)
must be a four-digit year
Sex
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Gender (optional, select all that apply)
Race and Ethnicity (optional, select all that apply)

Adult-Only Questions

Only ask the following questions to persons age 18 and older.
Have you ever served in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard, OR were you called to active duty as a member of the National Guard or as a Reservist?
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Do you have an alcohol or substance use disorder?
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Do you have a chronic health condition? (such as diabetes, cancer, heart disease, ongoing pain)
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Do you have a mental health disorder? (such as depression, anxiety, PTSD, schizophrenia)
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Do you have a physical disability? (such as mobility issues, vision impairment, hearing impairment)
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Do you have a developmental disability? (such as ADHD, autism, a learning disability, or an intellectual disability)
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Are you living with HIV or AIDS?
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Do any of those conditions keep you from actively maintaining employment or living independently?
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Are you a survivor of domestic violence?
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What is the main reason that you're homeless/unstably housed? (Check all that apply)
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Have you received any of the following services in the past 18 months?
Do you need any of these services?
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Do you receive income from any of the following sources?

Homelessness History

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Location


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If there are additional household members to survey, remember to submit the survey again for each additional household member.