Emergency Housing Voucher (EHV) Pre-Qualification Survey

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* 1. Are you currently living in a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings? This includes a car, park, abandoned building, bus station, airport, or campground?

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* 2. If you answered yes to Q1, please indicate where you slept last night

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* 3. Are you At Risk of Homelessness?

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* 4. If you answered yes to Q3, please indicate which of the situations below applies to you and your family:

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* 5. Are you currently Fleeing, or attempting to flee, domestic violence, dating violence, sexual assault, stalking, or human trafficking?  
*"Fleeing" means that you are actively fleeing the dangerous or life-threatening conditions, which has either taken place within your primary nighttime residence or has made you afraid to return.

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* 6. Are you recently homeless, for example, participating in a Rapid Re-Housing or Permanent Supportive Housing Program? Would you become homeless again if you did not receive rental assistance through this program?

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* 7. If you answered yes to Q6, what agency do you work with?

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* 8. I understand these are pre-qualification questions that will allow agencies to determine my eligibility for Housing Assistance.  I understand that this is only a pre-qualification questionnaire, and I will be contacted to complete an Emergency Housing Voucher application to continue my eligibility process.

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* 9. Please provide contact information for further eligibility follow up

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* 10. Alternate contact (if unable to reach you; case manager info would be helpful if applicable):

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