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HMIS of Summit County

 

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Point-in-Time Count Data

(Click Here for a Printable Version: PDF or WORD)

 

Complete form fields, then click on the SUBMIT button at the bottom of the page.

All completed information will be emailed directly to the City of Akron Planning Department.

 

DATE: January 26th, 2010!!! ONLY ENTER COUNTS FOR THIS DATE!!!

AGENCY: Please complete this form fore EACH Program listed for your Agency.

Agency/Program Name:

If other, enter Agency/Program name:

Program Type:

Address:

Agency Director:

Contact Person:

Telephone Number:

Fax Number:

E-mail:

 

BED/UNITS IN USE

Total Persons in Shelter: (Count for January 26th overnight)

 

# of Families in Shelter: Units    

Total Capacity Available: Units

Total Occupied on this date: Units

# of Persons in Families: Beds

 

Total # of Beds Available: Beds

Total Beds Occupied on this date: Beds

# of Single Persons in the Shelter:

 

AGE/GENDER BREAKDOWN (Count for January 26th overnight)

 

Number of Males:    

Under 18

Over 18

Over 65

 

Number of Females: 

Under 18

Over 18

Over 65

 

RACE/ETHNICITY BREAKDOWN (Count for January 26th overnight)

These %'s may add up to more than 100%.

Please enter numbers in % only!!!

 

% White

% Black or African American

% Black/African American and White

% Asian

% Asian and White

% Alaskan Native

% American Indian

% American Indian/Alaskan Native and Black

% American Indian/Alaskan Native and White

% Native Hawaiian

% Pacific Islander

% Other Multi-Racial

% Hispanic

 

TYPE OF POPULATION SERVED (Count for January 26th overnight)

These %'s may add up to more than 100%.

Please enter numbers in % only!!!

 

% Chronic Substance Abusers

% Seriously Mentally Ill

% Dually Diagnosed

% Veterans

% Persons with HIV/AIDS

% Victims of Domestic Violence

% Youth

 

UNABLE TO ASSIST (Count for January 26th overnight)

 

Number of Families:

 Total Unable to Assist

  Number Ineligible 

  Number Turned away due to Lack of Space

 

Number of Persons in Families:

  Total Unable to Assist

  Number Ineligible

  Number Turned away due to Lack of Space

 

Number of Individuals:

 Total  Unable to Assist

  Number Ineligible

  Number Turned away due to Lack of Space

 

VOUCHERS (Count distributed for January 26th overnight)

 

# of Families                

# of Persons in Families 

# of Individuals        

 

Only Click Submit when you are 100% Done.