Hmis Data Collection Template For Annual Assessment - Coc Program

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HMIS Data Collection Template for ANNUAL ASSESSMENT – CoC Program
FOR TEXT FIELDS, USE BLOCK LETTERS. OTHERWISE, MARK APPROPRIATE BOXES WITH AN “X”
Fill out separate form for each household member and clip together.
Assessment Date (e.g., 08/24/2014) [All clients]
/
/
Month
Day
Year
CLIENT (name or other identifier)
INCOME AND SOURCES [Head of household and adults]
Income from any source?


No
Client doesn’t know


Yes
Client refused

[IF YES] Answer Yes or No for each of the following sources. If the response for a source is ‘Yes’, enter an
amount. If unsure of the exact amount, enter client’s best estimate.
Receiving income
If yes, amount from source (round to
Source of income
from source?
nearest dollar)

No
Earned income (i.e., employment income)

Yes
$
.
0
0

No
Unemployment Insurance

Yes
0
0
$
.

No
Supplemental Security Income (SSI)

Yes
$
.
0
0

No
Social Security Disability Income (SSDI)

Yes
$
.
0
0

No
VA Service-Connected Disability
Compensation

Yes
0
0
$
.

No
VA Non-Service-Connected Disability Pension

Yes
$
.
0
0

No
Private disability insurance

Yes
$
.
0
0

No
Worker’s Compensation

Yes
0
0
$
.

No
Temporary Assistance for Needy Families (TANF)

Yes
$
.
0
0

No
General Assistance (GA)

Yes
$
.
0
0

Retirement Income from Social Security
No
1
HMIS Data: ANNUAL ASSESSMENT FORM
July 2014

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