Form DX-351(GQV) Group Quarters Validation Questionnaire

OMB No. 0607-0809: Approval Expires 12/31/2008
U.S. DEPARTMENT OF COMMERCE

DX-351(GQV)

FORM
(2-27-2007)

Economics and Statistics Administration

U.S. CENSUS BUREAU

GROUP QUARTERS VALIDATION QUESTIONNAIRE
2008 Census Dress Rehearsal
MANAGEMENT ATTENTION
(For use by manager only)
Living Quarters Screener
1.

Is this address in the block
listed on the label or the
address listing page?
1
Yes ➞ Go to Question 2
2

APPLY ADDRESS LABEL HERE.
If the case is an Add – Apply Processing ID label here.

No ➞ Go to the Certification Tab
and mark (X) the "D1" box
in the Address Status
section

2.

INTRODUCTION

3.

Hello. My name is (Your name). I’m from the U.S. Census Bureau. (Show your identification badge.)
I’d like to speak with someone who knows where people live, could live, or stay at this
address or about the people that use the services provided here. Would that be you, or should
I speak with someone else? (Continue or re-read introduction if referred to another respondent.)
We are updating our list of addresses as an important part of the 2008 Census Dress
Rehearsal. This will help ensure that the 2010 Census is as accurate as possible. We
estimate that it will take approximately 10 minutes to conduct this interview. This notice
explains that your answers are confidential. (Provide a copy of the Privacy Act statement to the
respondent and allow time to read it.)
What is your name?

4a. We have your address listed as (read the address on the label above). Is this correct?
1
2

Yes ➞ Go to Question 5
No ➞ Go to Question 4b and make corrections in the space below.

4b. What is your correct address? (Complete for all added OLQs.)
House No.

Street Name

ZIP Code

Unit Designation

Building Name

Building No.

Rural Route ZIP Code

Rural Route Address

Physical Description/Location

(For ADDS only) Is this also your mailing address?
Yes
2
No
1

LCO

AA

USCENSUSBUREAU

State

County

Block

Map Spot

Address Register
Line No.
Page No.

5. Now I am going to ask you some questions to help me determine what kind of place
this is. Is this a soup kitchen, a facility that operates a regularly scheduled mobile
food van, or shelter for people experiencing homelessness?
1
Yes ➞ Go to Question 15
2
No ➞ Go to Question 6

6. Is this some type of facility, student housing, or group home?
1
2

Yes ➞ Go to Question 12
No ➞ Go to Question 7

7. Is this a hotel, motel, hostel, recreational vehicle (RV) park, campground,
carnival, marina, or racetrack?
1
Yes ➞ Go to Question 15
2
No ➞ Go to Question 8

8. Is this housing for people with a religious affiliation such as a convent, monastery,
or abbey?
1
Yes ➞ Go to Question 12
2
No ➞ Go to Question 9

9. Is this housing for workers, such as construction, migratory or farm workers, or for
students at Job Corps centers?
Yes ➞ Go to Question 12
1
2
No ➞ Go to Question 10

10. Is this a private residence?
1
2

Yes ➞ Go to Question 11
No ➞ Go to Question 12

11. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Housing Unit" box in the Address Status section.

12. Does anyone live or stay here?
1
2

Yes ➞ Go to Question 15
No ➞ Go to Question 13

13. Could anyone live or stay here?
1
2

Yes ➞ Go to Question 15
No ➞ Go to Question 14

14. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Nonresidential" box in the Address Status section.

15. What is the telephone number here?
—

—

16. Let me repeat the telephone number I just wrote down. (Read telephone number given in
Question 15 above.) Is that correct?
Yes ➞ Go to Question 17
2
No ➞ What is the correct telephone number?
1

—

—

➞ Go to Question 17

17. What is your job title?

Page 2

FORM DX-351(GQV) (2-27-2007)

18a. Next, I am going to show you a list. (Show respondent flashcard Side 1.) Which of these
BEST describes this place? Mark (X) one box.
1
Boarding school (except for schools for people with disabilities) ➞ Go to Question 18b
2
3
4

Correctional facility for adults or juveniles ➞ Go to Question 19
Fraternity or sorority house for students at a college, university, or seminary ➞ Go to Question 28
Group home (non-correctional) or residential treatment center (non-correctional) ➞ Go to
Question 21

5

Health care facility (e.g., skilled nursing facility, nursing facility, hospital, hospice) ➞ Go to
Question 24

6

Hotel, motel, hostel, single room occupancy units, inn, resort, lodge, or bed & breakfast ➞ Go to
Tab 7
Independent or assisted living facility ➞ Go to Tab 1
Military Quarters (e.g., barrack/dormitory, disciplinary barrack/jail, military treatment facility) ➞ Go to
Tab 15

7
8

9
10

11

12

13

14

15

Recreational vehicle (RV) park, campground, carnival, marina, or racetrack ➞ Go to Tab 10
Religious group living quarters intended to house members living in a group situation (e.g.,
convent, monastery, or abbey) [Type Code 902] ➞ Go to Tab 3
Residence hall or dormitory for students that is owned, leased, or managed either by a college,
university, or seminary, or by a private entity or organization [Type Code 501} ➞ Go to Tab 2
Schools for people with disabilities (e.g., schools for the physically or developmentally disabled)
[Type Code 405] ➞ Go to Tab 11
Soup kitchen, a facility that operates a regularly scheduled mobile food van, or shelter for people
experiencing homelessness ➞ Go to Question 25
Workers’ group living quarters or group housing at Job Corps centers (e.g., migratory farm
worker quarters, ranch housing, vocational training facilities, or housing for staff)
[Type Code 901] ➞ Go to Tab 8
Private residence – THIS ENDS OUR INTERVIEW. Thank you very much for answering
these questions. Go to the Certification Tab and mark (X) the "Housing Unit" box in the
Address Status section.

18b. At this address, is there housing for staff?
1
2

Yes ➞ Go to Question 18c
No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Nonresidential" box in the
Address Status section.

18c. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Tab 8
No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Nonresidential" box in the
Address Status section.

19. Is this correctional facility intended for adults or juveniles? Mark (X) one box.
1
2

Adults ➞ Go to Question 20
Juveniles [Type Code 203] ➞ Go to Tab 4

20. Now I am going to show you a list of types of correctional facilities. (Show respondent
flashcard Side 2.) Which of these BEST describes this correctional facility? Mark (X) one box.
1
Federal detention center (also include Metropolitan detention center, Metropolitan
Correctional Center, Bureau of Indian Affairs detention center, Immigration and Customs
Enforcement Service Processing Centers and contract detention facilities) [Type Code 101]
2
Federal prison [Type Code 102]
3
State prison [Type Code 103]
Go to
Tab 4
4
Local or county jail or a correctional facility operated by the American Indian and
Alaska Native (AIAN) tribal governments (also included are work farms and camps
holding people awaiting trial or serving short sentences) [Type Code 104]
5
Correctional residential facility (including a halfway house, restitution center,
prerelease center and work release center) [Type Code 105]

⎫
⎬
⎭

FORM DX-351(GQV) (2-27-2007)

Page 3

21. Which of the following BEST describes this facility?
Is this a . . . (read both) Mark (X) one box.
1

group home (non-correctional)? ➞ Go to Question 22

2

residential treatment center (non-correctional)? ➞ Go to Question 23

22. Is this group home intended for adults or juveniles? Mark (X) one box.
1
2

Adults [Type Code 801] ➞ Go to Tab 3
Juveniles [Type Code 201] ➞ Go to Tab 9

23. Is this residential treatment center intended for adults or juveniles? Mark (X) one box.
1
2

Adults [Type Code 802] ➞ Go to Tab 3
Juveniles [Type Code 202] ➞ Go to Tab 9

24. Which of the following BEST describes this facility?
Is this a . . . (read list) Mark (X) one box.
skilled nursing facility or nursing facility? [Type Code 301] ➞ Go to Tab 1
1
2
hospital including mental or psychiatric hospital? ➞ Go to Tab 6
3

in-patient, free-standing hospice facility? [Type Code 403] ➞ Go to Tab 5

25. Is this facility a shelter?
1
2

Yes ➞ Go to Tab 12
No ➞ Go to Question 26

26. Is this facility a soup kitchen?
1

Yes [Type Code 702] ➞ Go to Tab 13

2

No ➞ Go to Question 27

27. Is this a facility that operates a regularly scheduled mobile food van?
1

Yes [Type Code 704] ➞ Go to Tab 14

2

No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Nonresidential" box in the
Address Status section.

28. Is this a fraternity or sorority house that is recognized by a college, university, or
seminary?
1
Yes [Type Code 501] ➞ Go to Tab 2
2

Page 4

No – THIS ENDS OUR INTERVIEW. Thank you very much for answering these
questions. Go to the Certification Tab and mark (X) the "Housing Unit" box in the
Address Status section.

FORM DX-351(GQV) (2-27-2007)

SKILLED NURSING FACILITY, NURSING FACILITY, OR
INDEPENDENT OR ASSISTED LIVING FACILITY

1

1. What is the full name of this facility?

2. Next, I have some questions about the building at the address we just verified.
At this address is there . . .(Read each question below)

a. a skilled nursing unit or a nursing unit?
b. housing for staff?
c. independent or assisted living units?

1
1
1

Yes
Yes
Yes

2
2
2

No
No
No

3. Is EITHER Question 2a OR 2b above marked "Yes?"
1
2

Yes ➞ Go to Question 4
No ➞ Go to Question 17

4. Is the answer to Question 2a above "Yes" for skilled nursing unit or nursing unit?
1
2

Yes {Type Code 301] ➞ Go to Question 5
No ➞ Go to Question 7

5. Is the name of this skilled nursing unit or nursing unit exactly the same as the facility
name?
1
Yes
No ➞ Specify
2

6. What is the maximum number of residents who can live or stay here in the skilled
nursing unit or nursing unit at this address?
Maximum number of residents

7. Is the answer to Question 2b above "Yes" for housing for staff?
1
2

Yes ➞ Go to Question 8
No ➞ Go to Question 10

8. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901]➞ Go to Question 9
No ➞ Go to Question 10

9. What is the maximum number of staff who can live at this address?
Maximum number of staff

10. Is the answer to Question 2c above "Yes" for independent or assisted living units?
1
2

Yes ➞ Go to Question 11
No ➞ Go to Question 16

11. Do you have additional Questionnaires or a DX-322(GQV) Multiple Questionnaires List
for this address?
1
Yes ➞ Go to Question 12
No ➞ Go to Question 15
2

FORM DX-351(GQV) (2-27-2007)

Page 5

12. Now I’d like to read a list of addresses and ask you to tell me whether they are
independent or assisted living units here at this address. (Read addresses from
Questionnaires/list and mark each address confirmed as a HU, then go to Question 13.)

13. Other than the addresses we just talked about, are there any other independent or
assisted living units at this address?
Yes ➞ Go to Question 14
1
2
No ➞ Go to Question 16

14. What are the addresses of all these other independent or assisted living units
at this address? Go to the HU listing tab and list each of these units, then go to
Question 16.

15. Earlier you mentioned there are independent or assisted living units at this address.
What are the addresses of all these independent or assisted living units at this
address? Go to the HU listing tab and list each of these units, then go to Question 16.

16. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

For facility with ONLY independent or assisted living units

17. Do you have additional Questionnaires or a DX-322(GQV) Multiple Questionnaires List
for this address?
Yes ➞ Go to Question 18
2
No ➞ Go to Question 21
1

18. Now I’d like to read a list of addresses and ask you if they are independent or assisted
living units here at this address. (Read addresses from Questionnaires/list and mark each
unit identified as a HU, then go to Question 19.)

19. Other than the addresses we just talked about, are there any other independent or
assisted living units at this address?
1
Yes ➞ Go to Question 20
2
No ➞ Go to Question 22

20. What are the addresses of all these other independent or assisted living units at this
address? Go to the HU listing tab and list each of these units, then go to Question 22.

21. Earlier you mentioned there are independent or assisted living units at this address.
What are the addresses of all these independent or assisted living units at this
address? Go to the HU listing tab and list each of these units, then go to Question 22.

22. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "D3" box in the Address Status section.

Page 6

FORM DX-351(GQV) (2-27-2007)

RESIDENCE HALL, DORMITORY, OR FRATERNITY/SORORITY HOUSE
FOR COLLEGE, UNIVERSITY, OR SEMINARY STUDENTS
1. What is the full name of this residence hall, dormitory, fraternity or sorority house?

2. What is the maximum number of people who can live or stay here at this address?
Maximum number of people

3. What is the name of this college, university, or seminary? (Enter all that apply.)

2
4. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

FORM DX-351(GQV) (2-27-2007)

Page 7

RELIGIOUS GROUP LIVING QUARTERS INTENDED TO HOUSE
MEMBERS LIVING IN A GROUP SITUATION, GROUP HOME
(non-correctional) FOR ADULTS, OR RESIDENTIAL TREATMENT
CENTER (non-correctional) FOR ADULTS
1. What is the full name of this facility?

2. Next, I have a question about the building at the address we just verified. What
is the maximum number of people who can live or stay here at this address?
Maximum number of people

3. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

3

FORM DX-351(GQV) (2-27-2007)

Page 9

CORRECTIONAL FACILITY FOR ADULTS OR JUVENILES
1. What is the full name of this correctional facility?

2. At this address, is there more than one building where inmates can live or stay?
1
2

Yes ➞ Go to Question 9
No ➞ Go to Question 3

3. Is the name of this building exactly the same as the facility name?
1
2

Yes
No ➞ Specify name of building

4. What is the maximum number of inmates who can live or stay here?
Maximum number of inmates

5. At this address, in addition to housing for inmates, is there also housing for
staff?
1
2

Yes ➞ Go to Question 6
No ➞ Go to Question 8

6. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Question 7
No ➞ Go to Question 8

7. What is the maximum number of staff who can live at this address?
Maximum number of staff

4

8. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

9. How many buildings are there where inmates can live or stay?
Total number of buildings

10. Now I would like to ask you some questions about each of the buildings where
inmates can live or stay. List all buildings where inmates can live or stay. Ask both
Questions b and c for each building.

a.

Let’s
talk
about
the . . .

b.

What is the name or designation of
this building?

c.

What is the
maximum number
of inmates who can
live or stay here at
this building?
➞ Go to Question 10a
and ask about
the 2nd building

1st
building

Continue with Question 10 on the next page

FORM DX-351(GQV) (2-27-2007)

Page 11

10. Continued
a. Let’s b.
talk
about
the . . .

What is the name or designation of
this building?

c.

What is the
maximum number
of inmates who can
live or stay here at
this building?

2nd
building

Is there another
building?

3rd
building

Yes ➞ Go to
Question 10a
and ask about
the next building
No ➞ Go to
Question 12

4th
building
5th
building
6th
building
7th
building
8th
building
9th
building
10th
building
11th
building
12th
building
13th
building
14th
building
15th
building

11. If there are more buildings, go to DX-351CF(GQV), Correctional Facility Continuation Form,
then come back to Question 12.

12. Check to make sure the number of buildings listed agrees with the number of buildings in
Question 9.

13. At this address, in addition to housing for inmates, is there also housing for staff?
1
2

Yes ➞ Go to Question 14
No ➞ Go to Question 16

14. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Question 15
No ➞ Go to Question 16

15. What is the maximum number of staff who can live at this address?
Maximum number of staff

16. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

Page 12

FORM DX-351(GQV) (2-27-2007)

IN-PATIENT HOSPICE FACILITY (Free-standing only)
1. What is the full name of this facility?

2. Next, I have some questions about the building at the address we just verified.
What is the maximum number of patients who can live or stay here at this
address?
Maximum number of patients

3. At this address, in addition to housing for patients, is there also housing for
staff?
1
Yes ➞ Go to Question 4
No ➞ Go to Question 6
2

4. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Question 5
No ➞ Go to Question 6

5. What is the maximum number of staff who can live at this address?
Maximum number of staff

6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

5

FORM DX-351(GQV) (2-27-2007)

Page 13

HOSPITAL (including mental or psychiatric hospital)
1. What is the full name of this facility?

2. Is the name of this building exactly the same as the facility name?
1
2

Yes
No ➞ Specify name of building

3. Now I have some questions about the building at the address we just verified.
a. At this building . . . (Read each question below)

(1) is there a mental or
psychiatric unit or floor for
long-term care?

(2) is there an in-patient
hospice unit?

(3) is there a skilled nursing
unit?

(4) do you accept patients
with no disposition or exit
plan?

1
2

1
2

1
2

1
2

b. (If "Yes" in Question 3a, ask):
What is the maximum
number of these
patients?

Type
code

Yes ➞ Go to 3b
No

401

Yes ➞ Go to 3b
No

403

Yes ➞ Go to 3b
No

301

Yes ➞ Go to 3b
No ➞ Go to
Question 4

402

4. At this building, is there housing for staff?
1
2

Yes ➞ Go to Question 5
No ➞ Go to Question 7

5. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Question 6
No ➞ Go to Question 7

6. What is the maximum number of staff who can live at this address?
Maximum number of staff

7. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
If Question 3a(1), 3a(2), 3a(3), 3a(4), or 5 is answered "Yes," go to the Certification Tab and
mark (X) the "Group Quarters" box in the Address Status section.
If Questions 3a(1), 3a(2), 3a(3), 3a(4), and 5 are all answered "No," go to the Certification Tab
and mark (X) the "Nonresidential" box in the Address Status section.

6
FORM DX-351(GQV) (2-27-2007)

Page 15

HOTEL, MOTEL, HOSTEL, SINGLE ROOM OCCUPANCY UNITS,
INN, RESORT, LODGE, OR BED & BREAKFAST

7

1. What is the full name of this facility?

2. Next, I have some questions about the building at the address we just verified. Does
this building or part of this building regularly provide shelter for people experiencing
homelessness?
1
Yes [Type Code 701] ➞ Go to Question 3
No ➞ Go to Question 5
2

3. What is the maximum number of people experiencing homelessness who can
live or stay here?
Maximum number of people

4. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

5. Will you be open during March or April?
1
2

Yes ➞ Go to Question 6
No ➞ Go to Question 9

6. What is the maximum number of rooms available for rent at this location?
Maximum number of rooms

7. Are there any rooms occupied by people who live or stay here most of the time?
1
2

Yes ➞ Go to Question 8
No ➞ Go to Question 9

8. How many rooms do you expect to be occupied by people who live or stay here
most of the time during March or April?
Number of rooms

9. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Transient" box in the Address Status section.

FORM DX-351(GQV) (2-27-2007)

Page 17

WORKERS’ GROUP LIVING QUARTERS OR GROUP HOUSING
AT JOB CORPS CENTERS
(e.g., migratory farm worker quarters, ranch housing, vocational
training facilities, or housing for staff)
1. What is the full name of this facility?
➞Go to Question 2
No name ➞ Go to Question 3

2. Next, I have some questions about the building at the address we just verified. Is the
name of the building exactly the same as the facility name?
1
2

Yes ➞ Go to Question 4
No ➞ Specify name of building

Go to Question 4

3. Does this building have a name?
1

Yes ➞ Specify name of building

2

No ➞ Go to Question 4

Go to Question 4

4. What is the maximum number of people who can live or stay here at this
address?
Maximum number of people

5. What months of the year do students or workers usually live or stay here?
Mark (X) all that apply.
1
All year
January
2
February
3
March
4
April
5
May
6
June
7
July
8
August
9
September
10
October
11
November
12
December
13

6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

FORM DX-351(GQV) (2-27-2007)

Page 19

8

GROUP HOME (non-correctional) FOR JUVENILES OR RESIDENTIAL
TREATMENT CENTER (non-correctional) FOR JUVENILES
1. What is the full name of this juvenile facility?

2. Next, I have some questions about the building at the address we just verified. What
is the maximum number of juveniles who can live or stay here at this address?
Maximum number of juveniles

3. At this address, in addition to housing for juveniles, is there also housing for
staff?
1
2

Yes ➞ Go to Question 4
No ➞ Go to Question 6

4. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Question 5
No ➞ Go to Question 6

5. What is the maximum number of staff who can live at this address?

9

Maximum number of staff

6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

FORM DX-351(GQV) (2-27-2007)

Page 21

RECREATIONAL VEHICLE (RV) PARK, CAMPGROUND,
CARNIVAL, MARINA, OR RACETRACK
1. What is the full name of this facility?

2. What months of the year are you open? Mark (X) all that apply.
1
2
3
4
5
6
7
8
9
10
11
12
13

All year
January
February
March
April
May
June
July
August
September
October
November
December

3. What is the maximum number of sites, pads, slips, or units at this location?
Maximum number

4. How many sites, pads, slips, or units do you expect to be occupied during
March or April?
Number

10

5. Can we have a site map or plan of your grounds/facility/area that will indicate
the places where people can camp, park their recreational vehicles, or stay on
their boats?
1
Yes ➞ Collect the site plan, then go to Question 6
No ➞ Go to Question 6
2

6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Transient" box in the Address Status section.

FORM DX-351(GQV) (2-27-2007)

Page 23

SCHOOLS FOR PEOPLE WITH DISABILITIES
(e.g., schools for the physically or developmentally disabled)
1. What is the full name of this facility?

2. Next, I have some questions about the building at the address we just verified.
What is the maximum number of students who can live or stay here at this
address?
Maximum number of students

3. At this address, in addition to housing for students, is there also housing for staff?
1
2

Yes ➞ Go to Question 4
No ➞ Go to Question 6

4. Is the housing for staff used as their usual residence?
1
2

Yes [Type Code 901] ➞ Go to Question 5
No ➞ Go to Question 6

5. What is the maximum number of staff who can live at this address?
Maximum number of staff

6. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

11

FORM DX-351(GQV) (2-27-2007)

Page 25

SHELTER FOR PEOPLE EXPERIENCING HOMELESSNESS
(Emergency and Transitional) OR DOMESTIC VIOLENCE SHELTER
1. What is the full name of this shelter?

2. Is this facility a . . . (read both) Mark (X) one box.
1

2

shelter for people experiencing homelessness (emergency and transitional
shelter)? [Type Code 701]
domestic violence shelter? [Type Code 703]

3. What is the maximum number of people who can live or stay here?
Maximum number of people

4. In addition to providing housing, do you also operate a soup kitchen here for people
experiencing homelessness?
1
Yes [Type Code 702] ➞ Go to Question 5
2
No ➞ Go to Question 7

5. What is the full name of this soup kitchen?

6. What is the maximum number of people who can be served at a meal?
Maximum number of people

7. Do you also operate a regularly scheduled mobile food van?
1
2

Yes [Type Code 704] ➞ Go to Question 8
No ➞ Go to Question 9

8. What is the maximum number of people you can serve from this regularly
scheduled mobile food van?
Maximum number of people

9. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

12
FORM DX-351(GQV) (2-27-2007)

Page 27

SOUP KITCHEN

13

1. What is the full name of this soup kitchen?

2. What is the maximum number of people who can be served at a meal?
Maximum number of people

3. Do you also operate a regularly scheduled mobile food van?
1
2

Yes [Type Code 704] ➞ Go to Question 4
No ➞ Go to Question 5

4. What is the maximum number of people you can serve from this regularly
scheduled mobile food van?
Maximum number of people

5. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

FORM DX-351(GQV) (2-6-2007)

Page 29

REGULARLY SCHEDULED MOBILE FOOD VAN
1. What is the full name of this facility?

2. What is the maximum number of people you can serve from this regularly
scheduled mobile food van?
Maximum number of people

3. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

FORM DX-351(GQV) (2-27-2007)

Page 31

14

MILITARY QUARTERS (e.g., barrack/dormitory, disciplinary
barrack/jail, Military Treatment Facility)
1. What is the full name of this military installation?

2. Is this building a . . . (read all) Mark (X) one box.
1
2
3

barrack/dormitory – non-disciplinary? [Type Code 601]
disciplinary barrack/jail? [Type Code 106]
Military Treatment Facility? ➞ Go to Question 4

3. What is the maximum number of people who can be assigned to this
barrack/dormitory/jail?
Maximum number of people ➞ Go to Question 5

4. Now I have some questions about this Military Treatment Facility.
a. At this facility . . . (Read each question below)

(1) are there Active Duty
military personnel
assigned to a bed?

(2) do you accept patients
with no disposition or
exit plan?

1
2

1
2

b. (If "Yes" in Question 4a, ask):
What is the maximum
number of these
patients?

Type
code

Yes ➞ Go to 4b
No

404

Yes ➞ Go to 4b
No ➞ Go to
Question 6

402

5. THIS ENDS OUR INTERVIEW. Thank you very much for answering these questions.
Go to the Certification Tab and mark (X) the "Group Quarters" box in the Address Status section.

6. If question 4a(1) or 4a(2) is answered "Yes" – Go to the Certification Tab and mark (X) the
"Group Quarters" box in the Address Status section.
If questions 4a(1) and 4a(2) are answered "No" – Go to the Certification Tab and mark (X) the
"Nonresidential" box in the Address Status Section.

FORM DX-351(GQV) (2-27-2007)

Page 33

15

NOTES
For each note, enter the Page Number in column (1) and the Question Number in
column (2). Also enter the Note(s) on an INFO-COMM.
Page
number

Question
number

Note

(1)

(2)

(3)

NOTES

FORM DX-351(GQV) (2-27-2007)

Page 35

PAGE

OF

HU LISTING PAGE
UNIT
DESIGNATION

Is the Unit already listed
in the Address Register as
a HU?
Line No.
1
2

2

1
2
1
2

2

1
2

Line No.
1
2

1
2

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1
2

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2

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2

1
2

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2

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2

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2

1
2

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2

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2

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2

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2

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2

1
2

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2

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2

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2

1
2

2

1
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2

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1
2

1
2

Line No.
1
2

1
2

Line No.
1
2

1
2

Line No.
1
2

No
Yes ➞

2

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

Line No.

Page No.

No
Yes ➞

Page No.
1

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Please continue on the Housing Unit Continuation Form, DX-351HU(GQV).
FORM DX-351(GQV) (2-27-2007)

Page 37

HU Listing Page

Line No.
1

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Page No.

No
Yes ➞

Line No.

No
Yes ➞

Page No.

No
Yes ➞
Line No.

1

Is the Unit already listed
in the Address Register as
a HU?

Page No.

No
Yes ➞
Line No.

1

UNIT
DESIGNATION

ADDRESS STATUS
Mark (X) appropriate box below.

Group Quarters

Crew Leader Initials

Housing Unit
Nonresidential – Describe location on an INFO-COMM
Crew Leader Initials

Vacant – Describe location on an INFO-COMM
Transient
D1 – Cannot locate in listed block ➞ Describe location efforts in an INFO-COMM
Crew Leader Initials

Date Verified

D2 – Information for this questionnaire was collected on
Survivor Case ID No.

D3 ➞ Mark (X) only if directed to in Tab 1

CERTIFICATION
Sign and date the certification below.
I certify that the entries I have made on this questionnaire are correct to the best of my
knowledge.
Lister Name – Printed

Lister Signature

Supervisor Initials

Date

Date

1st CALLBACK
Date

2nd CALLBACK
Time

Lister Name

FORM DX-351(GQV) (2-27-2007)

Date

Time

a.m.
p.m.

2nd REASSIGNMENT
Date

Lister Name

Date

Page 39

ADDRESS STATUS
CERTIFICATION

1st REASSIGNMENT

a.m.
p.m.