Homeless Encampment Report Form

Your Name

First NameLast Name

Your Email Address

example@example.com

Your Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date and Time Observed

Date

Hour MinutesAM/PM Option

Encampment Location (Address or Closest Landmark)

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Location Description (e.g., intersection, park, underpass)

Estimated Number of People Present

Visible Conditions (Check all that apply)

Safety Concerns (Check all that apply)

Urgent Needs Observed (Check all that apply)

Upload a Photo (optional)

Additional Notes or Comments