Revised 7/12/19
LOS ANGELES UNIFIED SCHOOL DISTRICT
POLICY BULLETIN
ATTACHMENT
STUDENT HOUSING QUESTIONNAIRE (SHQ)
The McKinney-Vento Homeless Assistance Act, part of Every Student Succeeds Act (ESSA), entitles all school-aged children experiencing
homelessness access to the same free, appropriate public education that is provided to non-homeless youth. Schools are required to remove barriers
to enrollment, attendance, and academic success of students experiencing homelessness. To determine eligibility please complete this form. For
additional information, please contact the Homeless Education Office at (213) 202-7581.
Is the student: (check all that apply): a parenting teen? an unaccompanied youth? a runaway?
Has the student transferred schools any time after completing the second year of high school? Yes No
If yes, forward a copy of SHQ to school’s academic counselor for AB1806 eligibility.
Is the student currently living in one of the Nighttime Residence options listed below?
❏ YES ❏ NO
If you answered “NO” to this question, please STOP and sign below. If you answered “YES”, complete the remainder of the form.
CHECK (
Ö
) ONE OF THE NIGHTTIME RESIDENCE OPTIONS THAT BEST DESCRIBES YOUR
CURRENT LIVING SITUATION DUE TO THE LOSS OF HOUSING:
Shelter (ex. Homeless, Domestic Violence…etc)
Name: ______________________________________
Motel or Hotel
Name: _____________________________________
Car, trailer, or campsite
Temporarily in another family’s house or apartment
Temporarily with an adult that is not the parent or guardian
Transitional Housing Program
Name: ______________________________________
Trailer/motor home on private property
Other places NOT designated for or ordinarily used as a regular sleeping accommodation for human beings
Explain: __________________________________________________________________________________________________________
Is the student in need of services? ❏ YES ❏ NO
If yes, please check the services being requested.
Backpack/School Supplies Hygiene Kits Transportation Assistance *
*If you are requesting transportation assistance, please read and sign the affidavit below:
I need assistance from LAUSD, as I have no alternate means to deliver my child to school. I agree to have my child attend school every day and on
time. I also agree to notify the District if our situation changes or we no longer require this assistance. I understand that my child must meet the
eligibility criteria for transportation assistance and I must comply with sign-in and supervision requirements.
If transportation is denied, the School-Site Homeless Liaison will be notified. Parent/Guardian can appeal.
Parent/Guardian’s Initials: _______ Date: ________
Is the student in need of a referral for additional resource(s)? ❏ YES ❏ NO
If yes, please check the referral(s) being requested.
❏ Clothing Assistance: Shoes, Clothing, Uniforms ❏ Tutoring ❏ Housing Referrals ❏ Assistance for a Parenting Teen
***Designated School Site Homeless Liaison must conference with family to facilitate the requested referral(s)***
Your Designated School Site Homeless Liaison is:
Do you have other preschool and/or school aged children in the home? ❏ YES ❏ NO
If yes, please complete an additional SHQ. All sibling(s) must have an SHQ on file at their school site.
AFFIDAVIT- By signing this form, I declare under penalty of the laws in the State of California that the foregoing is true and correct.
In addition, I understand that the District reserves the right to verify the above listed residence information.
Signature of Parent/Legal Guardian/Caregiver: _______________________________ Date: ________
SCHOOL PLEASE NOTE:
ü Upon completion, please fax to (213) 580-6551 OR scan and email SHQ to your corresponding Local District:
shqldc@lausd.net, shqlde@lausd.net, shqldne@lausd.net, shqldnw@lausd.net, shqlds@lausd.net, or shqldw@lausd.net
ü SHQ MUST be kept in a CONFIDENTIAL file, which is separate from the permanent student record (this form must
NOT be placed in the cumulative file).
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