3-County Coc Hud Intake/exit Form (Universal Elements Only) Form

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3-County CoC HUD Intake/Exit Form (Universal Elements Only)
Program:
Client Information
Entry Date
/
/
mm/dd/yyyy
First Name
Middle Name
Last Name
Suffix ______
Name Code
___Full ___ Partial, Street or Code Name
___ Don’t Know ___ Refused
Social Security No.
SSN Data Code
___Full ___Approx./ Partial __DK ___Refused
Date of Birth
/
/
mm/dd/yyyy
DOB Data Code
___Full ___ Approx./ Partial __DK ___Refused
Race (check all that apply)
___American Indian/Alaska Native
___Asian
___Black/African American
___ Native Hawaiian / Pacific Islander
___White
___Don't know
___Refused
Ethnicity
____Hispanic/Latino
____Other (Non-Hispanic /Latino)
___Don't know
___Refused
Gender
____F
____M
___Trans MTF
___ Trans FTM
___Don’t know
___Refused
Other:
____Self /Head of Household
____Other Relation to HoH
Relationship to Head of
____HoH’s Spouse or
Household
Partner
____HoH’s Child
____Other, Non-Related
U.S. Military Veteran?
____Yes
____No
____DK
____Refused
Disabling Condition?
____Yes
____No
____DK
____Refused
Chronic Homelessness
For adult clients (18+)
Is the client entering from the streets, an emergency shelter or Safe Haven? _____ Yes _____ No
_____ Refused
_____DK
If yes, what is the approximate date when this episode of homelessness started?
(mm/dd/yyyy)
____/____/_______
Regardless of where they stayed last night - How many times has the client has been homeless on the streets, in ES,
or SH in the past three years including today?
_____ 0 (never in 3 yrs)
_____ 4 or more
_____ Don't know
_____ 1 (this is the first time)
_____ 2
_____ Refused
_____ 3
How many months has the client been homeless on the street, in ES, or SH in the past three years?
____ 1 month or less
____ months (write: 2 or 3 or etc...12)
____ More than 12 months
____ Don't Know
____ Refused
Staff: Is chronic homeless status documented?
_____ Yes
______ No
Last Updated: 10/26/2015
This form reflects the 2014 HMIS Data Standards, which HUD updated 9/2015. They take effect on 10/1/2015.
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