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Surveys
2015
September
G
Gaps and Needs
Gaps and Needs
Gaps and Needs Analysis Survey - Participants
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Hello:
You are invited to participate in our survey to identify what Homeless Needs and Gaps exist in your community. To try and serve you better, we want to ask you some questions about your situation. Please do not provide your name or anything that identifies who you are. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. Thank you very much for your time and support. Please start with the survey now by clicking on the
Continue
button below.
I Agree
What is your gender?
Male
Female
Other
Are you a veteran?
Yes
No
How old are you today?
18-25
26-30
31-40
41-50
50+
Are you disabled?
Yes
No
If you answered 'yes' to being disabled, please identify your disability?
Physical/Medical
Mental health
HIV/AIDS
Substance Abuse
Developmental
Other
If you identified a disability, is it
Clinically diagnosed
Self diagnosed
Are you currently homeless? (Living in shelter, transitional housing, on the street, or places not meant for human habitation.)
Yes
No
If homeless, check your reason() why: Check all that apply.
Domestic Violence
Family Break-up
Fire/other disaster destroyed my home
Unable to pay rent
Evicted due to non-payment of rent
Evicted for other reasons
Discharge from an institution
Other
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