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PREPARE
Record ID
Study ID
Participant Name
Date
Administrator Initials
Personal Characteristics
1. Are you Hispanic or Latino?
Yes
No
I choose not answer this question
2. Which race(s) are you? Check all that apply.
Asian
Pacific Islander
White
Native Hawaiian
Black/African American
American Indian/Alaskan Native
Other
I choose not to answer this question
2a. If other, please specify:
3. Have you been discharged from the armed forces of the United States?
Yes
No
I choose not answer this question
4. What language are you comfortable speaking?
English
Language other than English (please write)
I choose not to answer this question
Family & Home
5. Do you currently live with family members?
Yes
No
I choose not answer this question
5a. How many family members, including yourself, do you currently live with?
6. What is your housing situation today?
I have housing
I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)
I choose not to answer this question
7. Are you worried about losing your housing?
Yes
No
I choose not answer this question
8. What address do you live at? Please provide your street, city, state, and zipcode.
Money & Resources
9. What is the highest level of school that you have finished?
Less than high school degree
High school diploma or GED
More than high schoo
I choose not to answer this question
10. What is your current work situation?
Unemployed
Part-time or temporary work
Full-time work
Otherwise unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)
I choose not to answer this question
10a. If "otherwise unemployed but not seeking work", please specify:
11. What is your main insurance?
None/uninsured
Medicaid
CHIP Medicaid
Medicare
Other public insurance (not CHIP)
Other public insurance (CHIP)
Private insurance
12. During the past year, what was the total combined income for you and the family members you live with?This information will help us determine if you are eligible for any benefits. [Please leave blank if you choose not to answer]
13. In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? Check all that apply.
Food
Utilities
Clothing
Child Care
Medicine or Any Health Care (Medical, Dental, Mental Health, Vision)
Phone
Other
I choose not to answer this question
13a. If other, please specify:
14. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply.
Yes, it has kept me from medical appointments or from getting my medication
Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
No
I choose not to answer this question
16. Stress is when someone feels tense, nervous, anxious, or can't sleep at night because their mind is troubled. How stressed are you?
Not at all
A little bit
Somewha
Quite a bit
Very much
I choose not to answer this question
Money & Resources
17. In the past year, have you spent more than 2 nights in a row in a jail, prison, or juvenile correctional facility?
Yes
No
I choose not answer this question
18. Are you a refugee?
Yes
No
Unsure
I choose not answer this question
19. Do you feel physically and emotionally safe where you currently live?
Yes
No
Unsure
I choose not answer this question
20. In the past year, have you been afraid of your partner or ex-partner?
Yes
No
Unsure
I choose not answer this question
Submit Now
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