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* 1. Name

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* 2. University Email

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* 3. Phone

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* 4. What is your department/program?

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* 5. What year are you in your program?

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* 6. What is your enrollment status?

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* 7. At which campus do you work?

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* 8. What is your academic student employee (ASE) job title?

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* 9. Do you live on- or off- campus?

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* 10. What is monthly rental payment? Only include your portion if you live with roommates.

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* 11. What is your share of your monthly utility payment? Include electricity, gas, and water. Only include your portion if you live with roommates. 

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* 12. How long is your commute to work and school?

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* 13. The US Department of Housing and Urban Development provides the following definition for substandard housing. Does any part of this definition describe your living condition at any point since beginning your program?

1. Unit does not have hot and cold running water
2. Unit does not have a bathtub or shower
3. Unit does not have a flush toilet
4. Unit shares plumbing facilities 
5. Unit was cold for 24 hours or more and more than two breakdowns of the heating equipment have occurred that lasted longer than 6 hours
6. Electricity is not used
7. Unit has exposed wiring, not every room has working electrical plugs, and the fuses have blown more than twice
8. Unit has five or six of the following structural conditions: 
a. Unit has had outside water leaks in the past 12 months
b. Unit has had inside water leaks in the past 12 months
c. Unit has holes in the floor
d. Unit has open cracks wider than a dime
e. Unit has an area of peeling paint larger than 8 by 11 inches
f. Rats have been seen recently in the unit

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* 14. The United States Interagency Council on Homelessness provides the following definition of homelessness. Does any part of this definition describe your living situation at any point since beginning your program?

An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning: 
1. Has a primary nighttime residence that is a public or private place not meant for human habitation; 
a. Living in a vehicle falls into this category
2. Is living in a publicly or privately operated shelter designed to provide temporary living arrangements; 
3. Has not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days prior to the homeless assistance application; 
a. "Couchsurfing" or staying unofficially on a short term basis with friends or family falls into this category.

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* 15. How many times have you moved since entering your program?

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 16. Do you share a single bedroom with somebody who is not a family member or partner?

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* 17. Do you want to get involved in the union's campaign to fight to address the California housing crisis and win #COLA4ALL?

0 of 17 answered
 

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