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* 1. Are you a resident of Miami-Dade County

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* 2. If yes, which of these are true about your HIV infection? Please check only one answer.

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* 3. Which best describes you?

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* 4. What is your age (insert how many years)

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* 5. Which best describes you? Please check only one.

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* 6. Which race/ethnicity best describes you? (Please choose only one.)

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* 7. Do you speak English most of the time?

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* 8. How many people are living in your household?

  1 2 3 4 5 6 7 8
I live with my spouse or partner (please enter "1" if you live with your spouse or partner).
Enter the number of the number of children, ages 0-17, living in your household.
Enter the number of the number of children and other people, ages 18-24, living in your household.
Enter the number of children, brothers, sisters, other relatives and other adults, ages 25 and older living in your household.
What is the total number of people living in your household?

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* 9. Are any of the adults or children who live with you also living with HIV/AIDS?

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* 10. Including you, how many adults in your immediate family share money and share in paying the household bills? IF ONLY YOU, ENTER 1.

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* 11. Including today, how many times in the last 3 months did you visit a doctor, physician’s assistant, nurse practitioner, or nurse at a medical clinic for HIV treatment or care? Enter Number of Times (best estimate is fine).

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* 12. Using a scale from 1 to 10, where 1 is no medical problem and 10 is very severe medical problem(s), what is your health like now?

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* 13. Disability or Health Issues

  Yes/No I need or would like assistance
Other than HIV/AIDS, I have another long-term and serious medical condition or health problem, like diabetes, heart disease, hepatitis or cancer that disables me.
I have another long-term and serious medical condition or health problem, like diabetes, heart disease, hepatitis or cancer that does not disable me.
I am disabled by serious depression.
I am disabled by other mental illness.
I have Post-Traumatic Stress Disorder (PTSD).
I have a learning disability.
I have sight impairment.
I am hearing impaired.
My current drug and/or alcohol use.
My former drug and/or alcohol use.

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* 14. Do you have any conditions that impact your housing needs or ability to get and keep housing? (Please answer all that are true about you)

  Yes/No
I have symptoms of HIV/AIDS, such as neuropathy, fatigue, or dementia.
I have a physical impairment that affects my ability to get around.
I have a cognitive impairment, such as problems with my memory or thinking.
I experience depression or have a mental illness.
I have another condition that impacts my housing needs.

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* 15. Does your housing situation affect your ability to go to your HIV/AIDS doctor or other medical care provider to maintain your health?

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* 16. Does your housing situation affect your ability to take your HIV/AIDS medication?

  Yes/No
Living with family member(s) who don’t know I am HIV+
Living with roommate(s) who don’t know I am HIV+
Homeless and living on the street
Homeless and living in a shelter.
Homeless and living in a transitional housing program.
Unstable housing arrangements.
Lack of adequate storage for medicine in home (i.e. refrigeration, safe space).

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* 17. If you have needed an apartment modified or designed for someone with a physical condition or disability, how easy have you found them?

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* 18. Have you ever stayed in a residential treatment program or a hospital or crisis unit because of nervousness, anxiety, depression, a mental illness?

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* 19. Have you ever stayed in a residential treatment program because of a problem with drugs or alcohol?

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* 20. If you answered yes, to one or both of the last two questions, did you lose the housing that you had before you went into treatment?

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* 21. Do you get paid for doing any work?

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* 22. If you are not working, would you like to go back to work?

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* 23. What is the total monthly income (all sources but food stamps) of all the adult members of your immediate household who share money and paying the bills?

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* 24. Please check all of the answers that are true about you.

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* 25. If you are not receiving SSI or SSDI, have you ever applied for such disability benefits?

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* 26. Please answer the following questions to help us understand your financial situation.

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* 27. What is the highest level of education you have completed?

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* 28. If you have been convicted of a misdemeanor and served time in jail, tell us how many times

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* 29. If you have been convicted of a felony and served time in prison, please tell us how many times.

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* 30. If you have been in jail or prison, when was the last time you were released?

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* 31. Please identify each offense for which you were convicted and whether it was a misdemeanor or felony?

  Misdemeanor (Yes/No) Felony (Yes/No)
Drug-Related
Criminal Mischief
Prostitution
Burglary, Theft
Armed Robbery
Sexual Offense
Battery/Other Violent Offense
Murder

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* 32. Where do you live now?

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* 33. Please pick the one kind of place that best describes where you are living today.

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* 34. Does this place have any of the following problems?

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* 35. Have you considered moving because of any of the following problems in your current building or neighborhood?

  In Your Neighborhood (Yes) In Your Building (Yes)
Drug activity
Criminal activity 
Violence
Prostitution
Noise
Gangs
Street harassment or many people hanging out
Stigma because of my HIV status
Physical harassment
Inability to safely walk to public transportation
No access to public transportation

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* 36. Does the government or another organization pay, or help pay, for your housing?

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* 37. If the government or another organization is paying, or helps pay, for your housing, please check all of the answers that are true about you:

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* 38. Are you on any waiting lists for government or other help to pay, or pay for a part of, your housing costs?

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* 39. If you are on any waiting lists for government or other help to pay, or pay for a part of, your housing costs, please check all of the answers that are true about you:

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* 40. If you moved in the last three years, how many times have you moved?

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* 41. Please tell us about all the reasons why you moved in the last three years (check all that apply).

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* 42. Did you leave your last place because your spouse or partner or someone else in your family was hurting you or threatening to hurt you? Being hurt or threatened includes being kicked, hit shoved, or beat up, or hurt with a knife or gun, or forced to have sex.

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* 43. Have you ever been homeless (meaning have to sleep in a place not meant to live in (e.g. lived on the streets, parks, in a car, safe haven program or emergency shelter)?

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* 44. How many times have you been homeless?

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* 45. Tell us how long you were homeless each time during the last three years.

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* 46. Please tell the reasons you became homeless (check all of the answers that are true about the last time you were homeless):

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* 47. If you stayed at an emergency shelter or homeless housing program, have you felt comfortable or uncomfortable sharing your HIV/AIDS status with the program staff?

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* 48. Have you had a problem with your landlord telling others about your HIV status without your permission?

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* 49. Have you been discriminated against for trying to get or keep housing?

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* 50. If you answered yes above to being discriminated against, please tell us the reasons (check all that apply)

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* 51. How did you respond to the discrimination when it happened? Check all that you did in response.

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* 52. Have you had other experiences that made housing difficult to get?

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* 53. Do you have an immigration problem or lack of legal documentation related to immigration, and if so, does that affect your ability to obtain housing?

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* 54. Tell us about your Housing Preference. Right now, would you rather:

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* 55. In addition to my answer above:

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* 56. If you had to move next month to a place you could afford, where would you prefer to move?

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* 57. Would you use these housing services? Please check Yes or No for each from the drop down box.

  Yes/No
Help finding housing or referral services such as lists of apartments or houses that you might be able to afford.
Help finding a roommate or apartment looking for new roommate
Someone to take you around to look at apartments
Help filling out housing applications and other forms
Help fixing problems with your credit history
Help clearing up your criminal record.
Assistance with first and last months rent and security deposit.
Assistance with reviewing or negotiating lease with a landlord/property manager.

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* 58. Please tell us if you are currently receiving any of the services or assistance listed below. Please also tell us which 3 are the most important to you to become or to stay stably housed. (Only check what YOU need, not what you think others need).

  Which of these services do you currently receive (mark yes to all you receive) Which three of these services are the most important to to become or stay stably housed (mark 3 yes)
Case Management
Medical care
Help managing medication
Mental health treatment/counseling
Substance abuse treatment
Spiritual counseling
Support group
Ex-Offender peer support group
Food assistance
In-home supportive services
Job training or support
Emergency housing assistance such as help with back-rent
Assistance with rent each month
Assistance with conflict I might have with my landlord/property manager
Assistance with making physical modifications to my rental home so that I may fully utilize the space
Help with budgeting, managing money
Child care
Assistance with re-unifying with my children
Parenting skill classes
Transportation
Legal help

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