Individual Vulnerability Index

Introduction

Different housing programs in Chicago offer different types of supports. This screening will help determine which housing program will best fit your needs. I will ask questions about things like your health experiences. Some of the questions are personal in nature and may be difficult to answer. If you do not feel comfortable answering a question, please ask me to skip it. The information you provide will be used to assess eligibility for housing programs and level of service intervention required.

If any of the questions are confusing or you don’t know how to answer, feel free to ask and I will be happy to clarify for you.

It’s up to you how honest you are in this survey, but the more truthful you are, the better we can match you to the right program and support you in finding stable housing.

PLEASE DO NOT PRINT THIS PAGE.  IF YOU NEED A PRINTED COPY, PLEASE PRINT THE ATTACHED PDF.

Length of Homelessness
1. What is the total length of time in days you have lived on the streets or shelter?
_______________
Disability and Hospitalizations
2. This question asks about a disabling condition, which means any condition that limits your ability to work or perform daily activities. Some examples include a substance abuse disorder, serious mental illness, developmental disability, or chronic physical illness. Have you been diagnosed with a disabling condition?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

2a. If so, would you like support accessing documentation from a doctor or other medical professional about the disabling condition?
Yes ___
No ___

3. How many times have you been to the emergency room in the past three months?
_______________

4. How many times have you been hospitalized as an inpatient in the past year?
_______________

Physical Healthcare
5. Do you have now, or have you have had, or has a healthcare provider ever told you that you have any of the following medical conditions?

Kidney Disease/End-Stage Renal Disease or Dialysis
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

History of Frostbite, Hypothermia, or Immersion Foot
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

History of Heat Stroke/Heat Exhaustion
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Liver Disease, Cirrhosis, or End-Stage Liver Disease
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Heart Disease, Arrhythmia, or Irregular Heartbeat
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

HIV or AIDS
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Emphysema
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Diabetes
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Asthma
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Cancer
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Hepatitis C
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Tuberculosis
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

Substance Use and Mental Health
6. Have you ever abused drugs/alcohol, or been told you do?
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

7. Have you consumed alcohol every day for the past month?
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

8. Have you ever used injection drugs or shots?
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

9. Have you ever been treated for drugs or alcohol abuse?
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

10. Are you currently or have you ever received treatment for mental health issues?
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___

11. Have you ever been taken to the hospital against your will for mental health reasons?
Yes___ No___ Client doesn’t know___ Client refused ___ Data not collected___