Student Residency Questionnaire/SRQ (English) for the PEIMS Homeless Status Indicator

This sample template is meant only to be an example of how a district might combine various components into a form that could collect the required information. This is not a mandated form—it is an example prepared for a hypothetical school district to serve as a starting point for districts. Likewise, there is no requirement that the respective information must be collected on a separate form—a form could be created that would combine the necessary components to make determinations about both homeless and unaccompanied youth status.