Homeless Families Baseline Interview

The Impact of Housing and Services Interventions for Homeless Families

Baseline Interview

Introduction 1

Section A: Pre-Shelter Housing 2

Section B: Housing Barriers 4

Section C: Homelessness History 6

Section D: Employment 9

Section E: Family Composition 13

Section F: Income and Income Sources 21

Section G: Family Head: Physical Health (Adult Health) 24

Section H: Family Head: Mental Health 26

PTSD Symptoms 27

Section I: Family Head Substance Use 29

Section J: Family Head: Foster Care/Group Home History/Criminal Justice History/Domestic Violence 32

Section K: Screening for Intervention Eligibility (TH Interventions) 33

Section L: Demographics 34

Section M: Contact Information 36

Introduction

NOTE: By the time of the baseline interview, the site liaison will have met with the respondent to explain the study and will have obtained informed consent. The introduction to the survey thus focuses only on the interview. The introduction provides assurances of confidentiality but does not repeat all of the consent form language. The site liaison will conduct the interview right after informed consent and before random assignment. In nearly all cases we assume this will all be part of one meeting between the site liaison and the head of the family in the shelter. The head of family is defined as the custodial parent or if both custodial parents are present in the shelter, the mother.

As I mentioned earlier, I work for Abt Associates, an independent research company. We are helping the U.S. Department of Housing and Urban Development (HUD) to do a study to find out what kind of housing assistance is best for families who become homeless. One of the things we are asking families who participate in the study to do is to answer questions for a survey to help us learn more about the kinds of experiences families have and the kinds of assistance that is most helpful to them. The survey will take about 40 minutes to complete. You can stop the interview at any time and you can choose not to answer any question. The information you provide will be kept confidential and only used for this study. The collection of this information has been approved by the Office of Management and Budget. At the end of the interview, you will be paid $35 in appreciation for your time.

Section A: Pre-Shelter Housing

First, I’d like to ask about your housing before you came to this shelter. I would like you to think back to the place where were you living right before you came to [SHELTER NAME]?

Which one of the following best describes your living situation right before you came to [SHELTER NAME]?

Would you say you were staying in…	YES	NO	REF	DK
A1a. A house or apartment that you owned or rented. This does not include your parent’s or guardian’s home or apartment	1	2	7	8
A1b. Your partner’s (boy/girlfriends/fiancé, significant other’s) place.	1	2	7	8
A1c. A friend or relative’s house or apartment, and paying part of the rent [PROBE: THIS INCLUDES YOUR PARENT’S or GUARDIAN’S HOUSE OR APARTMENT OR OTHER FRIEND OR RELATIVE’S APARTMENT]	1	2	7	8
A1d. A friend or relative’s house or apartment, but not paying part of the rent [PROBE: THIS INCLUDES YOUR PARENT’S or GUARDIAN’S HOUSE OR APARTMENT OR OTHER FRIEND OR RELATIVE’S APARTMENT]	1	2	7	8
CAPI: IF 1a, 1b, 1c, or 1d =Yes SKIP TO A2; Otherwise, continue down 1e through 1p until a yes response is reached.
A1e. A permanent housing program with services to help you keep your housing (on site or coming to you) IF YES: SKIP TO A4	1	2	7	8
A1f. A transitional housing program IF YES: SKIP TO A4	1	2	7	8
A1g. A voucher hotel or motel IF YES: SKIP TO A4	1	2	7	8
A1h. A hotel or motel you paid for yourself IF YES: SKIP TO A4	1	2	7	8
A1i. A residential drug or alcohol treatment program IF YES: SKIP TO A4	1	2	7	8
A1j. Jail or prison IF YES: SKIP TO A4	1	2	7	8
A1k. A domestic violence shelter IF YES: SKIP TO A4	1	2	7	8
A1l. An emergency shelter other than this one [NAME OF CURRENT SHELTER] IF YES: SKIP TO A4	1	2	7	8
A1m. A car or other vehicle IF YES: SKIP TO A4	1	2	7	8
A1n. An abandoned building IF YES: SKIP TO A4	1	2	7	8
A1o. Anywhere outside [PROBE: STREETS, PARKS, ETC.] IF YES: SKIP TO A4	1	2	7	8
A1p. OTHER  SPECIFY: __________________________ IF YES: SKIP TO A4	1	2	7	8

Source: adapted from TH study

How long [did you stay there/were you living there] before coming to [NAME OF SHELTER]?

INTERVIEWER: RESPONDENT CAN ANSWER IN THE TIMEFRAME MOST COMFORTABLE FOR THEM. IF RESPONDENT ANSWERS IN MONTHS AND YEARS, CONVERT TO MONTHS.

REPORTED TIME IN YEARS_ 1

REPORTED TIME IN MONTHS 2

REPORTED TIME BY DAYS 1-96

REFUSED 97

DON’T KNOW 98

A2a. RECORD TIME IN YEARS

Number of Years __________ 1-96

Less Than One Year 0 ASK A2b

REFUSED -2

DON’T KNOW -1

A2b. RECORD TIME IN MONTHS

Number of Months __________ 1-96

Less than One Month_______ 1 ASK A2c

REFUSED -2

DON’T KNOW -1

A2c. RECORD TIME IN DAYS

Number of Days __________ 1-31

REFUSED -2

DON’T KNOW -1

Source: New

What was your street address right before you came to [SHELTER NAME]?

A3a. Was there a complex/building name?

A3b. Was there an apartment number?

A3c. What city did you live in?

A3d. What state did you live in?

A3e. What was the zip code?

SKIP TO SECTION B

Source: New

How many months or years has it been since you had a regular place to stay, or regular housing? By “a regular place to stay” or “regular housing” I am referring to a house, apartment, room, or other housing where you could stay 30 days or more in the same place. PROBE: THIS COULD MEAN EITHER A HOUSE OR APARTMENT YOU OWNED OR RENTED ON YOUR OWN, OR A HOUSE OR APARTMENT BELONGING TO YOUR PARENTS, OTHER RELATIVES, OR FRIENDS, WHERE YOU COULD STAY FOR 30 DAYS OR MORE]

IF RESPONDENT ANSWERS IN MONTHS AND YEARS, CONVERT TO MONTHS.

REPORTED TIME IN YEARS_ 1

REPORTED TIME IN MONTHS 2

REPORTED TIME BY DAYS 1-96

REFUSED 97

DON’T KNOW 98

A4a. RECORD TIME IN YEARS

Number of Years __________ 1-96

Less Than One Year 0 ASK A4b

REFUSED -2

DON’T KNOW -1

A4b. RECORD TIME IN MONTHS

Number of Months __________ 1-96

Less than One Month_______ 1 ASK A4c

REFUSED -2

DON’T KNOW -1

A4c. RECORD TIME IN DAYS

Number of Days __________ 1-31

REFUSED -2

DON’T KNOW -1

Source: Adapted from National Survey of Homeless Assistance Providers and Clients (NSHAPC)

What was the address of that place?

[INTERVIEWER: COLLECT ALL KNOWN INFORMATION ABOUT ADDRESS]

A4a. Was there a complex/building name?

A4b. Was there an apartment number?

A4c. What city did you live in?

A4d. What state did you live in?

A4e. What was the zip code?

Source: New

Section B: Housing Barriers

Next, I’d like to ask about things that make it difficult at times for some people to find a place to live.

There are many things that can make finding a place to live difficult. I’m going to read a list of reasons why some people might have trouble finding housing. Please tell me if you think this is a big problem, a small problem, or not a problem at all for you and your family.

When trying to find a place to live is …	Big problem	Small problem	Not a problem at all	REF	DK
B1a. Not having enough income to pay rent a...	1	2	3	7	8
B1b. Inability to pay a security deposit or first/last month’s rent a…	1	2	3	7	8
B1c. Lack of transportation to look for housing a…	1	2	3	7	8
B1d. Poor credit history a…	1	2	3	7	8
B1e. Racial discrimination a…	1	2	3	7	8
B1f. Not being currently employed a…	1	2	3	7	8
B1g. No rent history at all a…	1	2	3	7	8
B1h. Recently moved to community and no local rent history a…	1	2	3	7	8
B1i. No reference from past landlords a…	1	2	3	7	8
B1j. A past eviction(s) a…	1	2	3	7	8
B1k. Problems with past landlords a…	1	2	3	7	8
B1l. Past lease violations a…	1	2	3	7	8
B1m. Having problems with police a…	1	2	3	7	8
B1n. Having a criminal record or background a…	1	2	3	7	8
B1o. Having a felony drug record, a…
B1p. Having three or more children in the household a…	1	2	3	7	8
B1q. Having teenagers in the household a…	1	2	3	7	8
B1r. Someone in the household under 21 years old a…	1	2	3	7	8
B1s. Someone in the household that has a disability a…	1	2	3	7	8

Source: Strengthening At-Risk and Homeless Young Mothers and Children Initiative Evaluation (Cunningham).

Section C: Homelessness History

Now I am going to ask you some questions about any experiences you may have had with homelessness in your lifetime. By homeless, I mean times when you didn’t have a regular place to stay and you were living in a homeless shelter or temporarily in an institution because you had nowhere else to go. Homeless can also include living in a place not typically used for sleeping such as on the street, in a car, in an abandoned building, or in a bus or train station. Please do not include any times when you may have stayed with friends or relatives because you did not have your own place to stay.

Source: Adapted from Center for Mental Health Services and the Center for Substance Abuse Treatment (CMHS/CSAT) Homeless Families Evaluation Homelessness History Module.

1. Just before you came to [NAME OF SHELTER] this time, how long had you been homeless? You can tell me this answer in days, weeks, months, or years, whichever is easiest for you. [INTERVIEWER/CAPI: RECORD NUMBER OF DAYS, WEEKS, MONTHS, YEARS IN C1a. IF 0, RECORD THAT AS WELL. THEN VERIFY THE C1a RESPONSE IN C1b.]

C1a. NUMBER OF DAYS

NUMBER OF WEEKS

NUMBER OF MONTHS

NUMBER OF YEARS

REFUSED -2

DON’T KNOW -1

C1b. I have recorded that, before you came to [NAME OF SHELTER] this time, you had been homeless for:

NUMBER OF DAYS

NUMBER OF WEEKS

NUMBER OF MONTHS

NUMBER OF YEARS

Is that correct?

YES 1

NO 2 (REPEAT UNTIL YES)

REFUSED 7

DON’T KNOW 8

2. Not including this time right now, How many other times, have you been homeless, in your lifetime? [INTERVIEWER/CAPI: COUNT CURRENT SPELL AS ONE TIME. RESPONSES MUST BE 1 OR GREATER. ZERO IS NOT AN ALLOWABLE VALUE]

NUMBER OF TIMES ______________

REFUSED -2

DON’T KNOW -1

IF RESPONDENT SAYS 0 OR NONE, ASK C2a; ELSE SKIP TO C3.

C2a.: So, just to confirm Is this the first time you have become homeless?

YES 1 SKIP TO C7

NO 2

REFUSED 7

DON’T KNOW 8

3. How old were you the first time you became homeless?

AGE ______________IF =>18, THEN SKIP TO C6. IF =<17, SKIP TO C5

REFUSED -2 ASK C4

DON’T KNOW -1 ASK C4

4. Would you say that you were 17 years old or younger?

YES 1

NO 2 SKIP TO C6

REFUSED 7

DON’T KNOW 8

5. At that time, were you with your parents, or were you on your own?

WITH MY PARENT(S) 1

ON MY OWN 2

OTHER (SPECIFY) 3

REFUSED 7

DON’T KNOW 8

I’d like to ask you how long you have been homeless altogether in your life. You can tell me this answer in days, weeks, months, or years whichever is easiest for you.

6. Altogether, what would you say is the total number of days, weeks, months, or years that you have been homeless in your life? [INTERVIEWER/CAPI: RECORD NUMBER OF DAYS, WEEKS, MONTHS, YEARS IN C5a. IF 0, RECORD THAT AS WELL. THEN VERIFY THE C5a RESPONSE IN C5b.]

C6a. NUMBER OF DAYS

NUMBER OF WEEKS

NUMBER OF MONTHS

NUMBER OF YEARS

REFUSED -2

DON’T KNOW -1

C6b. I have recorded that in your whole life you have been homeless for:

NUMBER OF DAYS

NUMBER OF WEEKS

NUMBER OF MONTHS

NUMBER OF YEARS

Is that correct?

YES 1

NO 2 (REPEAT UNTIL YES)

REFUSED 7

DON’T KNOW 8

7. As an adult, have you ever stayed with family or friends because you couldn’t find or afford a place of your own? [PROMPT IF NEEDED: BY AS AN ADULT, I MEAN SINCE YOU TURNED 18)

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

8. As an adult, in the last five years (or since you turned 18), what is the total number of days, weeks, months, or years that you have spent living with family or friends, because you couldn’t find or afford a place of your own? [PROMPT IF NEEDED: BY AS AN ADULT, WE MEAN SINCE YOU TURNED 18]. [INTERVIEWER/CAPI: RECORD NUMBER OF DAYS, WEEKS, MONTHS, YEARS IN C7a. IF 0, RECORD THAT AS WELL. THEN VERIFY THE C7a RESPONSE IN C7b.]

C8a. NUMBER OF DAYS

NUMBER OF WEEKS

NUMBER OF MONTHS

NUMBER OF YEARS

REFUSED -2

DON’T KNOW -1

C8b. I have recorded that, as an adult, in the past five years you have lived with friends or relatives for:

NUMBER OF DAYS

NUMBER OF WEEKS

NUMBER OF MONTHS

NUMBER OF YEARS

Is that correct?

YES 1

NO 2 (REPEAT UNTIL YES)

REFUSED 7

DON’T KNOW 8

Section D: Employment

Now I’d like to ask a few questions about your work experience.

Source: Adapted from employment series from MTO Interim Evaluation Follow-up Survey and Effects of Housing Vouchers on Welfare Families Follow-up survey

1. Last week, did you do any work for pay?

YES 1 SKIP TO D3

NO 2

REFUSED 7

DON’T KNOW 8

2. What is the main reason that you did not work for pay last week? (RECORD VERBATIM AND THEN CODE. DO NOT READ LIST)

Unable to work because of housing problems 1

Unable to work for health reasons 2

Has job but temporarily absent /seasonal work 3

Couldn’t find any work 4

Child care problems 5

Family responsibilities 6

In school or other training 7

Waiting for a new job to begin 8

Responsibilities for care of family member
with a disability 9

Retired 10

Disabled 11 skip to D4

OTHER (SPECIFY)_________________________________) 96

REFUSED 97

DON’T KNOW 98

3. Do you have a disability, that could include either a physical, emotional, or mental health condition, that limits or prevents you from working at a job for pay?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

4. Are you responsible for caring for a family member (child or adult) who has a disability? (IF D2=9, SKIP TO D6)

YES 1 CONTINUE TO D5

NO 2

REFUSED 7

DON’T KNOW 8

IF D4=NO, REFUSED, DON’T KNOW AND D1=YES SKIP TO D7. IF D4=NO, REFUSED, DON’T KNOW AND D1=NO, REFUSED, OR DON’T KNOW, SKIP TO D6

5. Do these responsibilities (caring for a family member with a disability), limit or prevent you from working at a job for pay?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

IF D1=YES, SKIP TO D7

6. When did you last work for pay? Can you tell me the month and year you last worked for pay?

DATE LAST WORKED MM____/YYYY______

HAVE NEVER WORKED FOR PAY -3 SKIP TO E1

REFUSED -2 SKIP TO E1

DON’T KNOW -1 ASK D6A

D6a. [PROBE IF R DOES NOT KNOW MONTH OR YEAR ASK. About how long ago would you say you last worked for pay?

_____ YEARS OR ______MONTHS

REFUSED -2

DON’T KNOW -1

SKIP TO SECTION E

[CAPI: ONLY ASK D7-D15 IF D1=1, YES, CURRENTLY WORKING]

7. Last week, did you have more than one job, including part-time and weekend work?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

8. How many hours per week do you usually work at your [main] job? (By main job, I mean the one at which you usually work the most hours.)

NUMBER OF HOURS________________ 1-84

REFUSED -2

DON’T KNOW -1

Now I have a few questions about the (main) job at which you worked last week. By main job I mean the one where you worked the most hours

9. When did you first start working at your (main) job? Can you tell me the month and year you started working at your (main) job?

_ __/__ __ __ __

MM YYYY

REFUSED -2

DON’T KNOW -1

D9a. PROBE IF R DOES NOT KNOW MONTH OR YEAR. About how long ago would you say you started working at your main job? RECORD THE LENGTH OF TIME.

_______YEARS

_______MONTHS.

REFUSED -2

DON’T KNOW -1

10. For your (main) job, what is the easiest way for you to report your total earnings before taxes or other deductions: hourly, weekly, monthly, annually, or on some other basis?

HOURLY 1

DAILY 2

WEEKLY 3

BI-WEEKLY (EVERY 2 WEEKS) 4

TWICE MONTHLY 5

MONTHLY 6

ANNUALLY 7

PER UNIT 8

OTHER (SPECIFY___________________________) 96

REFUSED 97

DON’T KNOW 98

11. Do you usually receive overtime pay, tips, or commissions (at your main job)?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

12. Including overtime pay, tips, and commissions), what are your usual [REFER TO PAY FREQUENCY REPORTED IN D10] (hourly/daily/weekly/biweekly/twice monthly/ monthly/annual/per unit) earnings on this job, before taxes or other deductions?

ENTER DOLLAR AMOUNT $__ __ ,__ __ ___

REFUSED -2

DON’T KNOW -1

IF D10=2 CONTINUE TO D13

IF D10=7 CONTINUE TO D14

IF D10=8 CONTINUE TO D15

OTHERWISE SKIP TO SECTION E

13. [ASK THIS QUESTION ONLY OF PEOPLE WHO REPORT BEING PAID ON A DAILY BASIS D10=2] How many days a week do you usually work?

NUMBER OF DAYS ______________

REFUSED -2

DON’T KNOW -1

14. [ASK THIS QUESTION ONLY OF PEOPLE WHO REPORT BEING PAID ON A DAILY BASIS D10=2 OR ANNUAL BASIS D10=7] How many weeks a year do you get paid for?

NUMBER OF WEEKS ______________

REFUSED -2

DON’T KNOW -1

SKIP TO SECTION E

15. [ASK THIS QUESTION ONLY OF PEOPLE WHO REPORT BEING PAID BY THE UNIT D10=8] For how many [UNITs] are you usually paid per week (on this job)?

NUMBER OF UNITS ______________

REFUSED -2

DON’T KNOW -1

Section E: Family Composition

Now I’d like to ask you about the people in your family. First, I’ll ask you about people in your family who are with you now. Then, I will ask about those who are part of your family but not here in [NAME OF SHELTER] with you.

Source: Adapted from TH Study Family Roster, MTO HH Roster, and Voucher Study HH Roster

1. What is your marital status? Are you currently…

Single, never married 1

Married or living in a marriage like situation 2

Widowed 3

Separated/Divorced 4

REFUSED 7

DON’T KNOW 8

2. How many adults, that is, people who are 18 years old or older, in your family are living with you right now in [NAME OF SHELTER]?

NUMBER OF ADULTS ______________

REFUSED -2

DON’T KNOW -1

CAPI: IF 0 SKIP TO E4; ELSE GO TO E3

3. Please tell me the first names of the adults in your family who live with you right now in [NAME OF SHELTER]. Do not include yourself. By adult, I mean people who are 18 years old or older.

E3a.

E3a.

CAPI: LOOP UNTIL NAMES COLLECTED FOR NUMBER OF ADULTS REPORTED IN E2

4. How many children in your family are living with you right now in [NAME OF SHELTER]? By children I mean people 17 years old or younger.

NUMBER OF CHILDREN ______________

REFUSED -2

DON’T KNOW -1

CAPI: IF 0 SKIP TO E5; ELSE GO TO E4a

E4a. Please tell me the first names of the children in your family who live with you right now in [NAME OF SHELTER]. By children I mean people 17 years old or younger.

E4a1.

E4a2.

CAPI: LOOP UNTIL NAMES COLLECTED FOR NUMBER OF CHILDREN REPORTED IN E4

5. Do you have a spouse, partner, or significant other who is part of your family but is not living with you right now in [NAME OF SHELTER]?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

E5a. Now, can you please tell me the first name of your spouse/partner/significant other who is part of your family but is not living with you right now in [NAME OF SHELTER]?

NAME____________________________________________________

(spouse or partner who is part of family but not living with Respondent right now)

SPOUSE/PARTNER IS NOT PART OF FAMILY 1

6. Do you have any of your own children who are part of your family but are not living with you right now in [NAME OF SHELTER]? By children I mean people 17 years old or younger. Please do not include children 18 years old or older. Do not include yourself.

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

E6a. How many of your own children are not living with you now? By children I mean people 17 years old or younger. Please do not include children 18 years old or older.

NUMBER OF CHILDREN ______________

REFUSED -2

DON’T KNOW -1

E6b. Now, can you please tell the first name(s) of any of your children who are part of your family but are not living with you right now in [NAME OF SHELTER] By children I mean people 17 years old or younger. Please do not include children 18 years old or older. Do not include yourself.

E6b1.

E6b2.

E6b3.

Now, I would like to ask you some questions about your family members who are here with you now in [NAME OF SHELTER]. Let’s start with the adult(s). [COMPLETE THE ROSTER FIRST FOR FAMILY MEMBERS LIVING TOGETHER IN [NAME OF SHELTER]. CAPI WILL INCLUDE A CHECK THAT EVERYONE NAMED IN E3 AND E4a IS ASKED ABOUT IN ROSTER. MORE COLUMNS WILL BE ADDED AS NEEDED

	ADULT FAMILY MEMBER 1 (E3a)	ADULT FAMILY MEMBER 2 (E3b)	CHILD FAMILY MEMBER 3 (E4a1)	CHILD FAMILY MEMBER 4 (E4a2)
What is [E3a]’s relationship to you?	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6 Son- or Daughter-in-law 7 Mother or Father 8 Step-Parent 9 Mother- or Father-in-law or partner's parent 10 Grandparent 11 Brother or Sister 12 Brother- or Sister-in-law 13 Grandchild 14 Other Relative 15	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6 Son- or Daughter-in-law 7 Mother or Father 8 Step-Parent 9 Mother- or Father-in-law or partner's parent 10 Grandparent 11 Brother or Sister 12 Brother- or Sister-in-law 13 Grandchild 14 Other Relative 15	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6 Son- or Daughter-in-law 7 Mother or Father 8 Step-Parent 9 Mother- or Father-in-law or partner's parent 10 Grandparent 11 Brother or Sister 12 Brother- or Sister-in-law 13 Grandchild 14 Other Relative 15	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6 Son- or Daughter-in-law 7 Mother or Father 8 Step-Parent 9 Mother- or Father-in-law or partner's parent 10 Grandparent 11 Brother or Sister 12 Brother- or Sister-in-law 13 Grandchild 14 Other Relative 15
Is [E3a] male or female?	MALE 1 FEMALE 2 REFUSED 7 DON’T KNOW 8	MALE 1 FEMALE 2 DON’T KNOW 7 REFUSED 8	MALE 1 FEMALE 2 DON’T KNOW 7 REFUSED 8	MALE 1 FEMALE 2 DON’T KNOW 7 REFUSED 8
What is [E3a]’s Date of Birth?	___/___/_____ MM DD YYYY	___/___/_____ MM DD YYYY	___/___/_____ MM DD YYYY	___/___/_____ MM DD YYYY
ASK IF E3a is 15 or OLDER. Is [E3a] currently working for pay?	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF [E3a] is 15 OR OLDER. Does [E3a] have a disability that limits or prevents work?	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF E3a is 18 or OLDER. Has [E3a] ever been convicted of a felony for drug or other offenses?	YES 1 NO 2 REFUSED 7 DON’T KNOW 8 SKIP TO NEXT PERSON	YES 1 NO 2 REFUSED 7 DON’T KNOW 8 SKIP TO NEXT PERSON	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF [E4a1] IS 15 OR UNDER AND IF AN ADULT OF THE OPPOSITE GENDER FROM RESPONDENT LIVES WITH THE FAMILY: Does [E4a1]’s father/mother live with the family in [NAME OF SHELTER]?			YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF [E4a1] IS 15 OR UNDER: Was there ever a time when [CHILD] did not live with you?			YES 1 NO (SKIP TO E15) 2 REFUSED 7 DON’T KNOW 8	YES 1 NO (SKIP TO E15) 2 REFUSED 7 DON’T KNOW 8
ASK IF [E4a1] IS 15 OR UNDER: Please tell me all of the different places that [CHILD] has lived when s/he did not live with you. Did [CHILD] live … [MARK ALL THAT APPLY.]			With his/her other parent 1 With your Own parents or in-laws 2 With other relatives 3 In foster care 4  How long in foster care? ________months/years/days Other: ______________ 5	With his/her other parent 1 With your Own parents or in-laws 2 With other relatives 3 In foster care 4  How long in foster care? ________months/years/days Other: ______________ 5
ASK IF E4a1 IS 5 YEARS OLD OR OLDER. Is [E4a1] currently attending school?			YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF E4a1 IS 15 OR YOUNGER: Does [E4a1] have a disability? That could include either a physical, emotional, or mental health condition.			YES 1 NO (SKIP TO NEXT PERSON 2 REFUSED 7 DON’T KNOW 8	YES 1 NO (SKIP TO NEXT PERSON 2 REFUSED 7 DON’T KNOW 8
ASK IF E4a1 IS 15 OR YOUNGER AND E17=YES. What is E4a1’s disability? OPEN END

Now I’d like to ask you about your spouse/partner/significant other OR children who are part of your family but who are not with you now in [NAME OF SHELTER]. [Next, complete the roster for people mentioned in E5a and E6b, spouse/partner/significant other OR children who R considers part of the family but who are not with R in shelter. MORE COLUMNS WILL BE ADDED AS NEEDED

	FAMILY MEMBER 5 (E5a)	FAMILY MEMBER 6 (E6a1)	FAMILY MEMBER 7 (E6a2)	FAMILY MEMBER 8 (E6a3)
What is [E5a/E6a1’s] relationship to you?	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6	Husband or Wife 1 Lover/partner 2 child 3 Step-child 4 Foster child 5 Child of Lover/partner 6
Is [E5a/E6a1…] male or female?	MALE 1 FEMALE 2 REFUSED 7 DON’T KNOW 8	MALE 1 FEMALE 2 REFUSED 7 DON’T KNOW 8	MALE 1 FEMALE 2 REFUSED 7 DON’T KNOW 8	MALE 1 FEMALE 2 REFUSED 7 DON’T KNOW 8
What is [E5a/E6a1…]’s Date of Birth?	___/___/_____ MM DD YYYY	___/___/_____ MM DD YYYY	___/___/_____ MM DD YYYY	___/___/_____ MM DD YYYY
ASK IF [E5a] is 18 OR OLDER. Does [E5a] have a disability that limits or prevents work?	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF E5a is 18 or OLDER. Has [E5a] ever been convicted of a felony for drug or other offenses?	YES 1 NO 2 REFUSED 7 DON’T KNOW 8 SKIP TO FIRST CHILD IN E6a	YES 1 NO 2 REFUSED 7 DON’T KNOW 8 SKIP TO FIRST CHILD IN E6a	YES 1 NO 2 REFUSED 7 DON’T KNOW 8 SKIP TO FIRST CHILD IN E6a	YES 1 NO 2 REFUSED 7 DON’T KNOW 8 SKIP TO FIRST CHILD IN E6a
ASK IF [E6a1] IS 15 OR UNDER: How long has it been since [E6a1] lived with you?	_______ Year(s) ______ Month(s) [E5b] has never lived with R	_______ Year(s) ______ Month(s) [E5b] has never lived with R	_______ Year(s) ______ Month(s) [E5b] has never lived with R	_______ Year(s) ______ Month(s) [E5b] has never lived with R #
ASK IF [E6a1] IS 15 OR UNDER: Please tell where the [E6a1] is currently living, while not with you in [NAME OF SHELTER].	With his/her other parent 1 With your own parents or in-laws 2 With other relatives 3 In foster care 4  How long has [E6a1] been in foster care? ________months/years/days Other: ______________ 5	With his/her other parent 1 With your own parents or in-laws 2 With other relatives 3 In foster care 4  How long has [E6a2] been in foster care? ________months/years/days Other: ______________ 5	With his/her other parent 1 With your own parents or in-laws 2 With other relatives 3 In foster care 4  How long has [E6a3] been in foster care? ________months/years/days Other: ______________ 5	With his/her other parent 1 With your own parents or in-laws 2 With other relatives 3 In foster care 4  How long has [E6a4] been in foster care? ________months/years/days Other: ______________ 5
ASK IF [E6a1] IS 15 OR UNDER: What would you say has been the total amount of time [CHILD] has spent living apart from you?	_______ Year(s) ______ Month(s)	_______ Year(s) ______ Month(s)	_______ Year(s) ______ Month(s)	_______ Year(s) ______ Month(s)
ASK IF E6a1 IS 15 OR YOUNGER: Does [E6a1] have a disability? That could include either a physical, emotional, or mental health condition.	YES 1 NO (SKIP TO NEXT PERSON) 2 DON’T KNOW 7 REFUSED 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8	YES 1 NO 2 REFUSED 7 DON’T KNOW 8
ASK IF E6a1 IS 15 OR YOUNGER AND E27=YES. What is E6a1’s disability? OPEN END

Section F: Income and Income Sources

Now I would like to ask you about different sources of income or assistance you or people in your family who are with you now in [NAME OF SHELTER] may receive. Your responses to these questions will not affect your family’s eligibility for housing assistance or other types of assistance.

Source: Adapted from Effects of Housing Vouchers on Welfare Families Baseline Survey, with modifications

1. Thinking about the last month, (that is, the last 30 days), did you, or anyone in your family who is with you now, receive any assistance or income from…

[READ EACH SOURCE]

	YES	NO	REF	DK
F1a. Employment income	1	2	7	8
F1b. Food stamps?	1	2	7	8
F1c. SSI (Supplemental Security Income)?	1	2	7	8
F1d. TANF (Temporary Assistance for Needy Families, or welfare cash assistance)? [WILL INSERT LOCAL NAME OF TANF PROGRAM AND PROBE USING LOCAL NAME]	1	2	7	8
F1e Unemployment Compensation?	1	2	7	8
F1f. Child Support?	1	2	7	8
F1g. WIC (Women’s Infants, and Children)?	1	2	7	8
F1h. Social Security Disability Insurance (SSDI)	1	2	7	8
F1i. Social Security Survivor’s benefits?	1	2	7	8
F1j. Medicaid?	1	2	7	8
F1k. State health insurance? (e.g. GOLD CARD, INDIGENT CARE) [WILL INSERT LOCAL NAMES OF ANY STATE HEALTH INSURANCE OR ASSISTANCE]?	1	2	7	8
F1l. State Children’s Health Insurance Program (SCHIP)?	1	2	7	8
F1m. Child Care Assistance?	1	2	7	8
F1n. Alimony	1	2	7	8
F1o. Money from family or friends?	1	2	7	8
F1p. Other Sources of Income or Assistance (LIST)	1	2	7	8

2. During 2008 (or 2009 for those interviewed in 2010), what was the total combined income, before taxes or other deductions, of you and all the people who live with you now in [NAME OF SHELTER}? Please include money from jobs, work on the side, welfare, SSI, help from your family and friends, child support, alimony, and any other money income received by you or any other household member.

Source: Effects of Housing Vouchers on Welfare Families Follow-up survey

Enter dollar amount: $___ ____ ____ , ____ ____ _____

REFUSED -2 SKIP TO F3

DON’T KNOW -1 SKIP TO F3

F2a. I have entered $[amount from F2] as the total combined income in 2009 for you and all the people who live with you. Is this correct?

YES 1 SKIP TO SECTION G

NO 2 GO BACK TO F1

3. Would it amount to $10,000 or more?

YES 1

NO 2 SKIP TO F7

REFUSED 7 SKIP TO F7

DON’T KNOW 8 SKIP TO F7

4. Would it amount to $20,000 or more?

YES 1

NO 2 SKIP TO F6

REFUSED 7 SKIP TO F6

DON’T KNOW 8 SKIP TO F6

5. Would it amount to $25,000 or more?

YES 1 SKIP TO SECTION G

NO 2 SKIP TO SECTION G

REFUSED 7 SKIP TO SECTION G

DON’T KNOW 8 SKIP TO SECTION G

6. Would it amount to $15,000 or more?

YES 1 SKIP TO SECTION G

NO 2 SKIP TO SECTION G

REFUSED 7 SKIP TO SECTION G

DON’T KNOW 8 SKIP TO SECTION G

7. Would it amount to $5,000 or more?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Section G: Family Head: Physical Health (Adult Health)

The next few questions are about your health.

Source: Adapted from various sources about general health.

1. Overall, how would you rate your health during the past month (that is the past 30 days)?

Excellent 1

Very good 2

Good 3

Fair 4

Poor 5

REFUSED 7

DON’T KNOW 8

2. [INTERVIEWER/CAPI INSTRUCTION. ASK G2 ONLY IF RESPONDENT IS FEMALE]
   Are you currently pregnant?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Now I am going to ask you about whether you have certain medical conditions.

Source: G3 is taken from National Survey of Homeless Assistance Providers and Clients (NSHAPC).

3. Do you have any of the following medical conditions? Do you have [INSERT NAME OF CONDITION?]

Medical Condition	YES	NO	REF	DK
G3a. Sugar in your blood (diabetes)	1	2	7	8
G3b. Anemia (poor blood)	1	2	7	8
G3c. High blood pressure	1	2	7	8
G3d Heart disease	1	2	7	8
G3e. Stroke	1	2	7	8
G3f. Problems with your liver	1	2	7	8
G3g. Arthritis, rheumatism, joint problems	1	2	7	8
G3h. Chest infection, cold, cough, bronchitis	1	2	7	8
G3i. Pneumonia	1	2	7	8
G3j. Tuberculosis	1	2	7	8
G3k. Cancer	1	2	7	8
G3l. Problems walking, a lost limb, or other mobility impairment	1	2	7	8
G3m. Gonorrhea, syphilis, herpes, chlamydia, other STDs (NOT AIDS)	1	2	7	8
G3n. HIV positive	1	2	7	8
G3o. Have AIDS	1	2	7	8
G3p. Use drugs intravenously (shoot up)	1	2	7	8
G3q. Other (SPECIFY): _________________________	1	2	7	8

Section H: Family Head: Mental Health

The next questions are about how you have been feeling during the past 30 days (that is, the past month).

Source: National Co-Morbidity SurveyK+6 Interviewer administered sequence. http://www.hcp.med.harvard.edu/ncs/k6_scales.php¹

1. How much of the time during the past 30 days have you felt...

	All of the time	Most of the time	Some of the time	A little of the time	None of the time	REF	DK
H1a. Nervous?	1	2	3	4	5	7	8
H1b. Hopeless?	1	2	3	4	5	7	8
H1c. Restless or fidgety?	1	2	3	4	5	7	8
H1d. So depressed that nothing could cheer you up?	1	2	3	4	5	7	8
H1e. That everything was an effort?	1	2	3	4	5	7	8
H1f. Worthless?	1	2	3	4	5	7	8

PTSD Symptoms

Source: Modified FOA.²

Below is a list of the problems that people sometimes have after experiencing a traumatic event. I would like to ask you to think about the past two weeks.

2. I’m going to read each one and then ask you to indicate how much that problem has bothered you in the past 2 weeks. Please tell me whether each of the following problems have bothered you: Not at all, a little bit, Moderately, Quite a bit, or Extremely.

	NOT AT ALL	A LITTLE BIT	MODERATELY	QUITE A BIT	EXTREMELY	REF	DK
H2a. Repeated, disturbing memories, thoughts, or images of a stressful experience?	1	2	3	4	5	7	8
H2b. Repeated, disturbing dreams of a stressful experience?	1	2	3	4	5	7	8
H2c. Suddenly acting or feeling as if stressful experiences were happening again (as if you were reliving it)?	1	2	3	4	5	7	8
H2d. Feeling very upset when something reminded you of a stressful experience?	1	2	3	4	5	7	8
H2e. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience?	1	2	3	4	5	7	8
H2f. Avoid thinking about or talking about the stressful experiences or avoid having feelings related to it?	1	2	3	4	5	7	8
H2g. Avoid activities or situations because they remind you of a stressful experience?	1	2	3	4	5	7	8
H2h. Trouble remembering important parts of the stressful experience?	1	2	3	4	5	7	8
H2i. Loss of interest in things that you used to enjoy?	1	2	3	4	5	7	8
H2j. Feeling distant or cut off from other people?	1	2	3	4	5	7	8
H2k. Feeling emotionally numb or being unable to have loving feelings for those close to you?	1	2	3	4	5	7	8
H2l. Feeling as if your future will somehow be cut short?	1	2	3	4	5	7	8
H2m. Trouble falling or staying asleep?	1	2	3	4	5	7	8
H2n. Feeling irritable or having angry outbursts?	1	2	3	4	5	7	8
H2o. Having difficulty concentrating?	1	2	3	4	5	7	8
H2p. Being “super alert” or watchful on guard?	1	2	3	4	5	7	8
H2q. Feeling jumpy or easily startled?	1	2	3	4	5	7	8

Section I: Family Head Substance Use

Now I would like to ask you some questions about alcohol and drugs. These are questions about different experiences some people may have if they use drugs or alcohol. We are asking these questions of everyone in the study Remember that the information you provide will be kept confidential and will only be used for this study.

Source: Rapid Alcohol Problems Screen Cherpitel 1995d.³

1. Do you sometimes take a drink in the morning when you first get up?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

The next questions are about the past year. That is, since [MM/YYYY]

2. During the past year, has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

3. During the past year, have you had a feeling of guilt or remorse after drinking?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

4. During the past year, have you failed to do what was normally expected of you because of drinking?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

5. During the past year have you lost friends or boy/girlfriends because of drinking?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Source: I6 and I7 ADAPTED FROM DAST Drug Abuse Screening Test. This sequence was also used in the Transitional Housing Study.⁴

Now, I have some questions about illegal drugs. By illegal drugs, I mean things like marijuana (except when used for medicinal purposes), ecstasy, cocaine, crack, heroin, speed, uppers, downers, etc.

6. Thinking about the past year that is since [MM/YYYY]. (READ EACH CATEGORY AND MARK RESPONSE.)

	YES	NO	REF	DK
I6a. Have you used more than one drug at a time?	1	2	7	8
I6b. Have you had “blackouts” or “flashbacks” as a result of drug use?	1	2	7	8
I6c. Have your friends or relatives known or suspected that you used drugs?	1	2	7	8
I6d. Have you ever lost friends because of drugs?	1	2	7	8
Remember, this is in the past year…
I6e. Have you ever not spent time with your family or missed work because of drug use?	1	2	7	8
I6f. Have you engaged in illegal activities in order to obtain drugs?	1	2	7	8
I6g. Have you ever experienced withdrawal symptoms as a result of heavy drug intake?	1	2	7	8
I6h. Have you had medical problems as a result of drug use (e.g. memory loss, hepatitis, convulsions, bleeding?)	1	2	7	8

7. Now, thinking only about the past 30 days, have you regularly, that is 3 or more times a week, used an illegal drug? Again, by illegal drugs, I mean things like marijuana (except when used for medicinal purposes), ecstasy, cocaine, crack, heroin, speed, uppers, downers, etc. (Please do not include prescription drugs taken at the advice of a doctor or nurse.)

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Section J: Family Head: Foster Care/Group Home History/Criminal Justice History/Domestic Violence

Now I have a couple of questions about when you were a child and teenager. I’d like you to think about the time before you turned 18 years old.

Source: Foster care/group home questions are taken from National Survey of Homeless Assistance Providers and Clients (NSHAPC).

1. At any time before you turned 18 years old, were you ever placed in any of the following places? Were you placed in…

	YES	NO	REF	DK
J1a. A foster home?	1	2	7	8
J1b. A group home?	1	2	7	8
J1c. Any other kind of institution?	1	2	7	8

Now I’d like to have you think about any time during your entire life, including both childhood and adulthood.

2. Have you ever been convicted of a felony for drugs or other offenses?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Source: New

Now think only about your life as an adult, that is since you turned 18.

3. As an adult, have you ever been physically abused or threatened with violence by a person who you were romantically involved with, such as a spouse, boy/girlfriend, or partner?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Source: New

Section K: Screening for Intervention Eligibility (TH Interventions)

We will develop questions specific to each site to ensure that we screen for eligibility for TH programs available in the site under the TH intervention. This is an example. Full development of these questions cannot be done until sites are selected and requirements of TH programs in the interventions/sites are known.

1. Some housing programs require residents to be clean of drugs and sober to participate in their program. If staying clean and sober was a requirement for you, do you want to be considered for this program, or should we consider only the other options?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

2. Some programs require residents, to participate in treatment if deemed necessary by the program. If participating in treatment was a requirement for you do you want to be considered for this program, or should we consider only the other options?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

3. Some programs may require residents to work with case workers on a plan to get them ready to live on their own. If you had to work with a case worker to be part of this program, do you want to be considered for this program, or should we consider only the other options?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

THIS INFORMATION IS NECESSARY TO ENSURE THAT FAMILIES ARE ONLY SUBMITTED FOR RANDOM ASSIGNMENT FOR PROGRAMS THEY ARE ELIGIBLE TO RECEIVE. WE ARE EXPLORING WHETHER CAPI WILL PRODUCE REPORTS AT THE END OF INTERVIEW OR IF INTERVIEWER WILL RECORD RESPONSES ON DROP SHEET IN RESPONDENT INFORMATION BOOKLET (RIB) THAT THE INTERVIEWER WILL USE FOR EACH RESPONDENT.

Section L: Demographics

I have a few more questions about you.

1. What is your ethnic background? Are you:

Hispanic or Latino, or 1

Not Hispanic or Latino? 2

REFUSED 7

DON’T KNOW 8

2. What is your race? Please select one or more of the following:

INTERVIEWER: CODE ALL THAT APPLY.

American Indian or Alaskan Native 1

Asian, 2

Black or African American, 3

Native Hawaiian or Other Pacific Islander, or 4

White 5

OTHER (SPECIFY_______________) 96

REFUSED 97

DON’T KNOW 98

3. INTERVIEWER: RECORD RESPONDENT’S GENDER:

MALE / FEMALE [query or interviewer observation]

4. What is your Date of Birth?

____ ____ month

____ ____ date

____ ____ ____ ____ year

5. What is the highest grade or year of regular school that you have completed and gotten credit for?

Nursery School to 6th grade or no schooling 1

7th to 12th grade – NO DIPLOMA 2

High School Graduate/HAVE DIPLOMA 3

High School Equivalent (GED) General Educational Development 4

Some College 5

Technical Certificate 6

Associates Degree 7

Bachelors Degree 8

Masters Degree, Doctorate Degree, or other Professional Degree
(for example, MD, DDS, DVM, LLB, JD) 9

REFUSED 97

DON’T KNOW 98

6. Have you ever served on active duty in the Armed Forces of the United States?

YES 1

NO 2

REFUSED 7

DON’T KNOW 8

Source: HMIS Data Standards-language provided by VA

Section M: Contact Information

Thank you very much for your time today. To help us be able to get back in touch with you in the future, we would like to collect the names, telephone numbers and addresses of three people who will always know how to reach you. Please tell me about people who live at different addresses. This information will be kept strictly confidential and will only be used if we are unable to contact you.

1. Could you tell us the name of someone who does not live with you and will always know how to contact you?

Yes 1

No 2

REFUSED 7

DON’T KNOW 8

CONTACT #1:

2. What is his/her first name?

M2a. What is his/her middle name?

M2b. What is his/her last name?

M2c. Does his/her name have a suffix?

3. What is (his/her) street address?

M3a. Is there a complex/building name?

M3b. Is there an apartment number?

M3c. In what city?

M3d. In what state?

M3e. What is the zip code?

4. What is (his/her) home phone number, starting with the area code?

Telephone # with area code: (_______) ________-________

5. What is (his/her) cell phone number, starting with the area code?

Telephone # with area code: (_______) ________-________

6. What is (his/her) email address?

7. What is (his/her) relationship to you?

Friend 1

Relative [SPECIFY RELATIONSHIP] 2

OTHER (SPECIFY______________________________) 95

DON’T KNOW 97

REFUSED 98

CONTACT #2:

8. Could you tell us the name of a second person who does not live with you and will always know how to contact you?

Yes 1

No 2 SKIP TO CLOSING

REFUSED 7 SKIP TO CLOSING

DON’T KNOW 8 SKIP TO CLOSING

9. What is his/her first name?

M9a. What is his/her middle name?

M9b. What is his/her last name?

M9c. Does his/her name have a suffix?

10. What is (his/her) street address?

M10a. Is there a complex/building name?

M10b. Is there an apartment number?

M10c. In what city?

M10d. In what state?

M10e. What is the zip code?

11. What is (his/her) home phone number, starting with the area code?

Telephone # with area code: (_______) ________-________

12. What is (his/her) cell phone number, starting with the area code?

Telephone # with area code: (_______) ________-________

13. What is (his/her) email address?

14. What is (his/her) relationship to you?

Friend 1

Relative [SPECIFY RELATIONSHIP] 2

OTHER (SPECIFY______________________________) 95

DON’T KNOW 97

REFUSED 98

CONTACT #3:

15. Could you tell us the name of a third person who does not live with you and will always know how to contact you?

Yes 1

No 2 SKIP TO CLOSING

REFUSED 7 SKIP TO CLOSING

DON’T KNOW 8 SKIP TO CLOSING

16. What is his/her first name?

M16a. What is his/her middle name?

M16b. What is his/her last name?

M16c. Does his/her name have a suffix?

17. What is (his/her) street address?

M17a. Is there a complex/building name?

M17b. Is there an apartment number?

M17c. In what city?

M17d. In what state?

M17e. What is the zip code?

18. What is (his/her) home phone number, starting with the area code?

Telephone # with area code: (_______) ________-________

19. What is (his/her) cell phone number, starting with the area code?

Telephone # with area code: (_______) ________-________

20. What is (his/her) email address?

21. What is (his/her) relationship to you?

Friend 1

Relative [SPECIFY RELATIONSHIP] 2

OTHER (SPECIFY______________________________) 95

REFUSED 97

DON’T KNOW 98

CLOSING: Thank you very much for your time today. Do you have any questions for me about the study or what happens next?

1 Kessler, R.C., Barker, P.R., Colpe, L.J., Epstein, J.F., Gfroerer, J.C., Hiripi, E., Howes, M.J, Normand, S-L.T., Manderscheid, R.W., Walters, E.E., Zaslavsky, A.M. (2003). Screening for serious mental illness in the general population Archives of General Psychiatry. 60(2), 184-189.

2 Edna Foa, PhD, Professor of Clinical Psychology in the Department of Psychiatry of the University of Pennsylvania, PDS (Posttraumatic Stress Diagnostic Scale) test.

3 Cherpitel, Cheryl J., 1995. Screening for Alcohol Problems in the Emergency Room: A Rapid Alcohol Problems Screen. Drug and Alcohol Dependence. 40: 133-137.

4 Gavin DR; Ross HE; Skinner HA. (1989) 'Diagnostic validity of the Drug Abuse Screening Test in the assessment of DSM-III drug disorders', British Journal of Addiction 84(3): 301-307