Baseline - U-turn

Baseline - U-turn

Baseline captured on

Interviewer name

Who captured the baseline?

Location of Interview

Organisation/ Service Provider

Program

Client Name

Race text

Gender text

Race

Gender

Does the client currently have an ID document?

YesNo

ID Number (if known)

1a. Where do you usually sleep?

Street address / local landmark

City

Suburb

Other Suburb

1b. What type of structure did you sleep in last night?

Primary accommodation

Outside (street / doorway / under bridge / open land)TentInformal structure (cardboard / plastic / wood)Shelter (specify Name of Shelter)Backyard dwelling / HokkieBrick or concrete structureOther (specify)

Name of Shelter

other accommodation

1c. Where were you sleeping before you came to the area? (if applicable)

Previous Street address/ Landmark

Previous Suburb

1d. Where did you live before you became homeless?

Province originally from

Town/ City originally from

Other city originally from

Suburb originally from

2. How long have you been homeless and sleeping rough?

Length of time (months & years)

Time spent living on the street

Never	Less than a year
1 – 2 years	2 – 3 years
3 – 4 years	4 – 5 years
5 - 10 years	10 years +

3a. Why did you move to the streets the FIRST time?

Tick all that apply

Poverty

Left looking for work or other opportunities

Violence at home

Substance use

Gambling

Neglect / lack of support

Breakdown of relationship

Family lost home we were staying in

Discharged from an institution

Other (specify)

Specify other reason why moved to streets the first time

3b. Which institution did you stay in before you moved to the street the first time?

Name of Institution

3c. Have you ever been discharged from an institution on to the streets?

YesNo

Which type of institution?

Name of Institution

4. What are your main sources of income

Tick all that apply

AD hoc/ piece job employment

Donations at traffic light

Employment (full/part-time)

NGOs or EPWP

Friends/family

Income from tourists

Government grant

Income from residents or households

Park Cars

Recycling

Selling drugs

Sex Work

Other sources of income

Other main source of income

5a. Do you use alcohol or drugs?

[Tick all that apply]

Yes (Alcohol)

Yes (Drugs)

No

If yes - what do you normally use?

If the drug is not specified in the list above, please enter it here:

Tell me more (how often, last time etc.)

6. Have you ever been in treatment/ rehab?

YesNo

If yes, was it in-patient or out-patient?

In-patientOut-patient

7. What is your highest level of education?

No educationGrade 7 and lowerGrade 8 to 11MatricTertiary diploma/ degreeArtisan certificatePrompt: what is the last standard/ grade you passed in school?

8. Would you like any assistance to leave the streets?

8a. Have you been helped to leave homelessness before and it didn't work?

YesNo

What services did you receive?

ReunificationReintegrationRepatriationOther

Please specify other services (if applicable)

How long did it last before you became homeless again? (years and months)

8b. Would like assistance to leave streets

YesNo

What assistance would you like this time?

Other Assistance

Confidentiality Statement Signed

Any other relevant information given

Recommended next steps?

Hidden fields

U-turn Contact Id

Program (used in filters)

Prog Eng Id