HMIS Data Collection Template for Project ENTRY - COC Program - Flat Submitted by jeff on Tue, 07/02/2019 - 16:15 1 Start 2 Complete 0% PROJECT ENTRY DATE (All clients) * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20172018201920202021 Year First Name Middle Name Last Name NAME DATA QUALITY (All clients) Full name reported Partial, street name, or code name reported Client doesn't know Client refused SOCIAL SECURITY NUMBER (All clients) SOCIAL SECURITY NUMBER DATA QUALITY (All clients) Full SSN Reported Approximate or partial SSN reported Client doesn't know Client refused DATE OF BIRTH (All clients) MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Year DATE OF BIRTH TYPE (All Clients) Full date of birth Reported Approximate or partial date of birth reported Client doesn't know Client refused RELATIONSHIP TO HEAD OF HOUSEHOLD (All clients) Self (head of household) Head of household's child Head of household's Spouse or partner Head of household's other relation member Other non-relation member Head of household's other relation member (other relation to Head of household) RELATIONSHIP TO HEAD OF HOUSEHOLD (All clients) Head of household's other relation member (other relation to Head of household) RACE (All clients) RACE More than one race is permitted Client doesn'know and Client refused should only be selected if no other response is selected. (All clients) American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Client doesn't know Client refused ETHNICITY (All Clients) Non-Hispanic / Non-Latino Hispanic / Latino Client doesn't know Client refused GENDER (All clients) Female Male Transgender male to female Transgender female to male Other Client doesn't know Client refused HOUSING STATUS (All clients) Category: 1 -Homeless Category: 2-At imminent risk of losing housing Category: 3 - Homeless under other federal statutes Category: 4 - Fleeing domestic violence At-Risk of homelessness Stably Housed Client doesn't know Client refused CLIENT LOCATION (Head of Household) LENGTE OF TIME ON STREET (Head of Household and adults) Continuously homeless for at least one year? No Yes Client doesn't know Client refused Total Number of Months Homeless in the Past Three Years More than 12 Months Client doesn't know Client refused 0-12 months, specify #: Total Number of Months Homeless in the Past Three Years 0-12 months, specify #: (If more than 12 months) Number of Years Continuously Homeless Number of times the client has been homeless in the Past Three Years (do not include the current episode) 1 2 3 4 or more Client doesn't know Client refused Status Documented No Yes VETERAN STATUS (All Adults) No Yes Client doesn't know Client refused DISABLING CONDITION (All Adults) No Yes Client doesn't know Client refused RESIDENCE PRIOR TO PROJECT ENTRY [Head of household and adults) Emergency shelter, including hotel or motel paid for with emergency shelter voucher Foster Care Home or foster care group home Hospital or other residential non-psychiatric medical facility Hotel or motel paid for without emergency shelter voucher Jail, prison, or juvenile detention facility Long-term care facility or nursing home Owned by client, no ongoing housing subsidy Owned by client, with ongoing housing subsidy Permanent housing for formerly homeless persons (such as CoC project; HUD HOPWA PH) Place not meant for habitation (e.g., a vehicle, an abandoned building, bus train/subway station airport or anywhere outside) Psychiatric hospital or other psychiatric facility Rental by client, no ongoing housing subsidy Rental by Client, with VASH subsidy Rental by Client, with GPD TIP subsidy Rental by client, with other ongoing housing subsidy Residential project or halfway house with no homeless criteria Safe Haven Staying or living in a family member's room, apartment or house Staying or living in a friend's room, apartment or house Substance abuse treatment facility or detox Transitional Housing for homeless persons (including homeless youth) Client doesn't know Client refused Other: (Describe) RESIDENCE PRIOR TO PROJECT ENTRY [Head of household and adults) Other: (Describe) LENGTH OF STAY IN PREVIOUS PLACE [Head of household and adults] One day or less Two days to one week More than one week, but less than one month One to three months More than three months, but less than one year One year or longer Client doesn't know Client refused INCOME AND SOURCES [Head of household and adults] Income from any source? No Yes Client doesn't know Client refused [IF YES) on INCOME AND SOURCES, Enter enter the monthly amount received based on current income. If unsure of the exact monthly amount, enter client's best estimate. Earned income (i.e., employment income) Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability Income (SSDI) VA Service-Connected Disability Compensation VA Non-Service-Connected Disability Pension Private disability insurance Worker's Compensation Temporary Assistance for Needy Families (TANIF) General Assistance (GA) Retirement Income from Social Security Pension or retirement income from a former job Child support Alimony or other spousal support Other source: If Other specify source: Monthly Income from all sources: NON-CASH BENEFITS [Head of household and adults] Non-cash benefits from any source? No Yes Client doesn't know Client refused [IF YES] Select each non-cash benefit source: Do not select benefits that have been terminated, even if they were received in the past Special Supplemental Nutrition Assistance Program (SNAP) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) TANF Child Care services (or use local name) TANF transportation services (or use local name) Other TANF-Funded Services (or use focal name) Section 8, Public Housing, or other rental assistance Temporary rental assistance. If yes, specify source: Other source: [IF YES] Select each non-cash benefit source: Do not select benefits that have been terminated, even if they were received in the past Other source: HEALTH INSURANCE [All Clients] Covered by health insurance No Yes Client doesn't know Client refused [IF YES] Select each health insurance source: Do not select sources that have been terminated, even if they were received in the past. Medicaid Medicare Stale Children's Health Insurance Program Veteran's Administration (VA) Medical Services Employer-Provided Health Insurance Health insurance obtained through COBRA Private Pay Health Insurance State Health Insurance for Adults (or use local name) PHYSICAL DISABILITY (All Clients) No Yes Client doesn't know Client refused [IF YES for physical disability] is the physical disability expected to be of long, continued, Indefinite duration and substantially impairs the client's ability to live independently? No Yes Client doesn't know Client refused [IF YES for physical disability] Documentation of the disability and Its severity on file? No Yes Client doesn't know Client refused [IF YES for physical disability] Is client currently receiving services/treatment for this disability? No Yes Client doesn't know Client refused DEVELOPMENTAL DISABILITY [AIl Clients] Does client currently have a developmental disability? No Yes Client doesn't know Client refused [IF YES for developmental disability] Does the developmental disability substantially impair the client's ability to live independently? No Yes Client doesn't know Client refused [IF YES for developmental disability] Documentation of the disability and its severity on file? No Yes Client doesn't know Client refused [IF YES for developmental disability] Is the client currently receiving services/treatment for this disability? No Yes Client doesn't know Client refused CHRONIC HEALTH CONDITION [All Clients] No Yes Client doesn't know Client refused [IF YES for chronic health condition] is the chronic health condition expected to be of long, continued, indefinite duration and substantially Impairs the client's ability to live independently? No Yes Client doesn't know Client refused [IF YES for chronic health conditions] Documentation of the disability and its severity on file? No Yes [IF YES for chronic health condition] Is client currently receiving services/treatment for this condition? No Yes Client doesn't know Client refused HIV/AIDS [All Clients] No Yes Client doesn't know Client refused [IF YES for HIV/AIDS) Is HIV/AIDS expected to substantially impair the client's ability to live independently? No Yes Client doesn't know Client refused [IF YES for HIV/AIDS] Documentation of the disability and its severity on file? No Yes Client doesn't know Client refused YES for HIV client currently receiving services/treatment for this condition? No Yes Client doesn't know Client refused MENTAL HEALTH PROBLEM [All Clients] No Yes Client doesn't know Client refused [IF YES for mental health problem] Is the mental health problem expected to be of long, continued, indefinite duration and substantially impairs the client's ability to live independently? No Yes Client doesn't know Client refused [IF YES for mental health problem] Documentation of the disability and its severity on file? No Yes [IF YES for mental health problem] Is client currently receiving services/treatment for this condition? No Yes Client doesn't know Client refused SUBSTANCE ABUSE PROBLEM (All Clients) Does client currently have a substance abuse problem? No Alcohol abuse Drug abuse Both alcohol and drug abuse Client does't know Client refused [IF YES for alcohol abuse, drug abuse, or both alcohol and drug abuse for substance abuse problem is the substance abuse problem expected to be of long, continued, Indefinite duration and substantially Impairs client's ability to live Independently? No Yes Client doesn't know Client refused [IF YES for alcohol abuse, drug abuse, or both alcohol and drug abuse for substance abuse problem) Documentation of the disability and its severity on File? No Yes [IF YES for alcohol abuse, drug abuse, or both alcohol and drug abuse for substance abuse problem] Is client currently receiving services/treatment for this condition? No Yes Client doesn't know Client refused DOMESTIC VIOLENCE (Head of household and adults) Is client a domestic violence victim/survivor? No Yes Client doesn't know Client refused [IF YES] When did the experience occur? Within the past three months Three to six months ago (excluding six months exactly) Six months to one year ago (excluding one ... year exactly) One year ago or more Client doesn't know Client refused Submit
