Instructions for completing Housing Questionnaire

  • Printable version of Housing Questionnaire form available here.

    INSTRUCTIONS FOR COMPLETING THE HOUSING QUESTIONNAIRE Purpose of the Housing Questionnaire All Local Education Agencies (LEAs) are required to identify students experiencing homelessness. LEAs include school districts, charter schools and BOCES. Additionally, all LEAs that receive Title I funds must ask enrolling students about their housing status. The New York State Education Department (NYSED) encourages all LEAs regardless of whether they receive Title I funds to do the same. To collect this information, LEAs may:

    1. Use the Housing Questionnaire attached here,
    2. Update/modify the Model Enrollment Form – Housing Questionnaire to address the needs of the LEA, or
    3. Incorporate the housing status question from the Model Enrollment Form - Residency Questionnaire into the LEA’s Enrollment Form or other documents already used by the LEA during the enrollment process.

    If an LEA elects the third option and incorporates the housing status question into the LEA’s Enrollment Form, the LEA should take steps to ensure that a student’s housing status does not become a part of the student’s permanent record, because of the sensitive nature of this information. Please see the section titled “Confidentiality” (below) for information about how and when housing information may be shared within the LEA.

    Who should fill out the Housing Questionnaire?

    A Housing Questionnaire should be filled out for all students enrolling in school and for all students who have a change of address in grades preschool-12. “Preschool” includes any LEA administered or funded preschool program, such as a prek or Head Start program administered by an LEA. The Housing Questionnaire should be completed by the student’s parent, person in parental relation, or in the case of an unaccompanied youth, by the student directly.


    Student housing information should be kept confidential to the maximum extent possible. This information should only be shared with LEA/school staff members who need information about housing status to ensure that the student’s educational needs are met. To this end, LEAs may share a student’s Housing Questionnaire with LEA personnel such as:

    1. the LEA liaison,
    2. the registrar,
    3. the student’s teachers, and/or guidance counselor, and
    4. the LEA staff member responsible for reporting data to SED However, this information should only be shared with the above staff members to the extent that it will enable them to better meet the educational needs of the student in question and to fulfill reporting requirements mandated by SED.

    Other than the above uses, housing information should be kept confidential and should not be shared with other LEA/school personnel due to its sensitive nature and the stigma attached to being labeled homeless. LEAs are also encouraged to seek out ways of preventing Housing Questionnaires and housing information from becoming a part of a student’s permanent record.

    Discussing the Housing Questionnaire with Students and Families

    In reviewing the Housing Questionnaire with parents, persons in parental relation, and unaccompanied youth, LEAs should emphasize that the purpose of gathering the information is to ensure that students in temporary housing arrangements are provided with the rights and services to which they are entitled under the McKinney-Vento Act. These rights and services include:

    1. The right to stay in the same school the student had been attending before losing his/her housing or the last school attended (both known as the school of origin),
    2. The right to immediate enrollment for students who decide to transfer schools, even if the student does not have all of the documents normally for enrollment,
    3. Transportation services if the student continues to attend the school of origin,
    4. Categorical eligibility for Title I services if offered in the LEA, 5. Categorical eligibility for free meals if offered in the LEA, and 6. Access to services provided with McKinney-Vento funds if available in the LEA.

    The LEA should also ensure that the parent, person in parental relation, unaccompanied youth is aware that the student’s housing status will kept confidential and will only be shared with those LEA staff who are responsible for providing services to the student and those responsible for keeping track of how many students are identified as living in temporary housing in the LEA.

    LEAs are advised to explain to parents that if a parent claims that her/her child is living in temporary housing, and the LEA wishes to conduct an investigation to verify this information, the LEA may conduct a home visit. However LEAs cannot contact a landlord or building superintendent to verify a student’s housing status without prior parental consent. Contacting a landlord or building superintendent without the parent’s express prior written permission is a violation of FERPA, a federal law.

    If the Parent, Person in Parental Relation, or Unaccompanied Youth Declines to Fill Out the Housing Questionnaire If the parent, person in parental relation, or unaccompanied youth declines to complete the Housing Questionnaire, the LEA should note on the form that the parent, person in parental relation, or unaccompanied youth declined to provide the information requested.

    Completing the Form If a parent, person in parental relation, or unaccompanied youth enrolling in school indicates that a student is living in one of the five temporary housing arrangements, the school may not require proof to verify where the student is living before enrolling the student. The five temporary housing arrangements are listed below:

    1. In a shelter,
    2. With another family or other person (sometimes referred to as “doubled-up”),
    3. In a hotel/motel,
    4. In a car, park, bus, train, or campsite, or
    5. Other temporary living situation.

    After the student is enrolled and attending classes, the school or LEA is permitted to verify the student’s housing arrangements. However, the student must first be enrolled in school. Again, LEAs cannot not contact a landlord or building superintendent to verify a student’s housing status. (See above for more information.)

    Definitions of Temporary Housing Arrangements

    “With another family or other person” (also referred to as “doubled-up”)” LEAs should be aware that students who are sharing the housing of others are eligible for services under the McKinneyVento Act and State law, if sharing housing is due to loss of housing, economic hardship, or a similar reason.

    “Other temporary living situation” In addition to the four examples of temporary housing, students who lack a “fixed, adequate, and regular” nighttime residence are also covered as homeless under the McKinney-Vento Act and State law. This may include unaccompanied youth who have fled their homes or were forced to leave their homes and who do not otherwise meet the definition of “doubled-up.”

    “In permanent housing” Permanent housing means that the student’s living arrangements are “fixed, regular, and adequate.”

    Next Steps for LEAs with Students Living in Temporary Housing Arrangements

    If the parent, person in parental relation, or unaccompanied youth indicates that a student is living in temporary housing, the LEA must complete a Designation Form. If the LEA believes additional information is needed before reaching a final decision on the student’s eligibility under McKinney-Vento, enrollment should not be delayed and a Designation Form should still be filled out. For more information about determining eligibility see the National Center on Homeless Education’s Determining Eligibility Brief, available at:

    If a student who is identified as homeless was last permanently housed in a different school district, the district of attendance/local district will be eligible for tuition reimbursement from SED for the cost of educating the student. School districts should complete a STAC-202 form if eligible for tuition reimbursement. For more information about STAC-202 forms contact the STAC Office at 518-474-7116 or NYS-TEACHS at 800-388-2014.

    Rev. 11/15/16


Housing Questionnaire form

  • NOTE TO SCHOOLS/LEAS: Please assist students and families filling out this form. The form should be included at the top page of registration materials that the district shares with families. Do not simply include this form in the registration packet, because if the student qualifies as residing in temporary housing, the student is not required to submit proof of residency and other required documents that may be part of the registration packet.

    Name of LEA:   Middletown City School District

    Name of School:▁▁▁▁▁▁

    Name of Student:   Last▁▁▁▁▁▁, First▁▁▁▁▁▁, Middle▁▁▁▁▁▁

    Gender:  Male▁▁, Female▁▁  Date of Birth: Month▁▁, Day▁▁, Year▁▁  Grade: PreSchool-12▁▁▁ ID number: (optional)▁▁▁

    Address:▁▁▁▁▁▁  Phone:▁▁▁▁▁▁

    The answer you give below will help the district determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they don’t have the documents normally needed, such as proof of residency, school records, immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

    Where is the student currently living? (Please check one box.)

    • In a shelter▁▁
    • With another family or other person because of loss of housing or as a result of economic hardship (sometimes referred to as “doubled-up”)▁▁
    • In a hotel/motel▁▁
    • In a car, park, bus, train, or campsite▁▁
    • Other temporary living situation (Please describe):▁▁
    • In permanent housing▁▁

    Print Name of Parent or Guardian or student (for unaccompanied homeless youth):▁▁▁▁▁▁

    Signature of Parent or Guardian or student (for unaccompanied homeless youth):▁▁▁▁▁▁


    If ANY box other than “In Permanent Housing” is checked, , then the student/family should be immediately referred to the MV Liaison. In such cases, proof of residency and other documents normally needed for enrollment are not required and the student is to be immediately enrolled. After the student has been enrolled, the district/school must contact the previous district/school attended to request the student's educational records, including immunization records, and the enrolling district's LEA liaison must help the student get any other necessary documents or immunizations.

    NOTE TO SCHOOLS/LEAS: If the student is NOT living in permanent housing, please ensure that a Designation Form is completed.

    Rev. 11/15/16