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* 1. What is the name of your Agency or Organization?

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* 2. Who will serve as the agency point of contact for Point-in-Time?

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* 3. Point of contact phone number

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* 4. Point of contact e-mail

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* 5. Name of program(s) or location(s) that will be conducting the count, including address (e.g. PATH, ACT team, Resource Center, Lobby, etc...)

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* 6. List the on-site Point of Contact for each location listed above - Name, phone, email. If agency P.O.C. will be present, please note this.

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* 7. Population(s) served by your agency:

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* 8. How many individuals experiencing homelessness do you expect to serve or come in contact with during the 2018 Point in Time Count - Monday, January 29th evening - Tuesday, January 30th evening? Please estimate or give a range.

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* 9. County(ies) your agency serve

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* 10. Which day(s) will you conduct the PIT survey:

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* 11. MDHI will attempt to recruit volunteers for all agencies that request them. 
Would your agency like to request volunteers to assist staff with administering the survey?

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* 12. If yes, List the shift times you would like to host volunteers, and number you would like to arrive (e.g. specific location if multiple; 9am -12pm; 3 volunteers)

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* 13. Do any of the locations for volunteers have special instructions? (e.g. where to park, wear a coat as table will be near an open doorway, etc.)

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* 14. Any other comments or information you would like MDHI to know?  Any other way we can be of assistance?

Thank you for your participation in the 2018 Point-in-Time effort! Accuracy is a whole community effort, and we appreciate your engagement. We will be in touch with further information regarding a Point of Contact training, and confirmation of your volunteer needs (if requested).
If you have any questions please feel free to contact Diane Howald - diane.howald@mdhi.org.

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