Your feedback is important to us. Please complete the short survey about the HOPWA services you have received.

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* 1. Name of the agency that assisted you with a HOPWA referral:

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* 2. How long have you been a client of this agency?

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* 3. What type of HOPWA assistance have you received in the past 12 months? (Check all that apply)

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* 4. For each month of assistance used, what event or circumstance led to the need for HOPWA assistance? (Check all that apply).

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* 5. Number of days you were homeless during the past 12 months?

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* 6. Number of residences you were living in during the past 12 months?

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* 7. How would you describe your overall health today?

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* 8. What is your current living situation?

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* 9. Have you and your case manager developed a housing plan that will result in a stable housing situation independent of future HOPWA assistance?

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* 10. Have you and your case manager discussed emergency preparedness?

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* 11. Please select the answer that best describes you:

  All the time Most times Sometimes Rarely Never Does not apply
Are you able to contact your case manager quick enough to meet your needs?
Is your case manager responsible and professional?
Overall, are you satisfied with the HOPWA services you have received in the past 6 months?
Has the HOPWA program met your housing assistance needs?
About You

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* 12. Your gender is

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* 13. Your race/ethnicity is

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* 14. Are you Hispanic?

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* 15. How old are you?

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* 16. You have completed this survey

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