Annual Snapshot Survey Submission Form

Use on one day between October 8-14, 2007. Submit your totals by Friday, October 19.

A PDF version of this form is available for printing.

Please review the instructions before completing this survey form.

If you need additional assistance , contact Phil Rydman. Thank you!


1.	Individuals Served
	(a)	Number of Males:
	(b)	Number of Females:
	(c)	Total Individuals Served:
2.	Age
	(a)	Under 18:
	(b)	18-25:
	(c)	26-35:
	(d)	36-45:
	(e)	46-64:
	(f)	65+:
3.	Racial/Ethnic Data:
	(a)	White:
	(b)	Black:
	(c)	Hispanic:
	(d)	Asian:
	(e)	Native American (Indian):
	(f)	Other Ethnic Groups:
4.	Veterans:
	(a)	Male Veterans
	(a)	Male Non-Veterans:
	(b)	Female Veterans
	(b)	Female Non-Veterans:
	For Veterans, which of the following (if any) are true?
	(c)	Served in Korea during the Korean War
	(d)	Served in Vietnam during the Vietnam Conflict
	(e)	Served in the Persian Gulf (Afghanistan or Iraq)
5.	Family Services
	(a)	Couples Together:
		No. of Families	No. of individuals
	(b)	Women with Child(ren)
		No. of Families	No. of individuals
	(c)	Man with Child(ren):
		No. of Families	No. of individuals
	(d)	Family (Man/Woman/Child(ren):
		No. of Families	No. of individuals
6.	Homeless more than one year:
	(a)	Yes:
	(b)	No:
7.	How many times have you been homeless before this time:
	(a)	Never:
	(b)	Once:
	(b)	Twice:
	(b)	3 + times:
8.	Have you stayed in this city for more than six months:
	(a)	Yes:
	(b)	No:
9.	While homeless, in the last twelve months, have you been a victim of physical violence?
	(a)	Yes:
	(b)	No:
10.	How often do you come to the mission for assistance?
	(a)	Every day
	(b)	At Least Once a Week
	(c)	At Least Once a Month
11.	Lost government benefits in the past twelve months?
	(a)	Yes:
	(b)	No:
12.	Prefer to receive services from an agency with a spiritual emphasis
	(a)	Yes:
	(b)	No:
13.	How many people are staying in long-term rehab programs?
	(a)	Men
	(b)	Women
14.	Number of clients staying in your facilities (i.e. rehab) who were not counted elsewhere on this form.
	(a)	Men
	(b)	Women
	(c)	Children