Form Hud-40110-C - Annual Progress Report (Apr) - Housing Opportunities For Persons With Aids (Hopwa) Program Page 27
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29Background information on Universal Data Elements for Homeless Management Information Systems
(HMIS), may be used by HOPWA projects to help coordinate assistance (Optional Format and edits *).
Data Element
Response Category
2.1 Name
First Name Middle Name Last Name Suffix
Current Name
Other Name Used to Receive Services
Previously
2.2 Social Security Number
1=Full SSN Reported
2=Partial SSN Reported
8=Don’t Know or Don’t Have SSN
9=Refused
2.3 Date of Birth
Month/Day/Year: __/-__/____
2.4 Ethnicity and Race
Ethnicity
0=non-Hispanic/Latino
1=Hispanic/Latino
Race (* items 6-10 added to HMIS list)
1=American Indian or Alaskan Native
6= American Indian or Alaskan Native
2=Asian
and White
3=Black or African-American
7=Asian and White
4=Native Hawaiian or Other Pacific
8=Black or African-American and
Islander
White
5=White
9=American Indian or Alaskan Native
and Black or African-American
10=Other Multi-Racial
2.5 Gender
0=Female
1=Male
2.6 Veteran Status
0=No
1=Yes
8=Don’t Know
9=Refused
2.7 Disability Status
0=No
1=Yes
8=Don’t Know
9=Refused
2.8 Residence Prior to Program Entry
1=Emergency shelter
2=Transitional housing for homeless persons
3=Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP,
or SRO Mod Rehab)
4=Psychiatric hospital or other psychiatric facility
5=Substance abuse treatment facility or detox center
6=Hospital (non-psychiatric facility)
7=Jail, prison or juvenile detention facility
10=Rented room, apartment, or house
11=House you own
12=Staying or living in someone else’s (family and friends) room, apartment, or house
13=Hotel or motel paid for without emergency shelter voucher
14=Foster care home or foster care group home
15=Place not meant for habitation (e.g., a vehicle, an abandoned building,
bus/train/subway station/airport, or anywhere outside)
16=Other
8=Don’t Know
9=Refused
Length of Stay in Previous Place
1=One week or less
2=More than one week, but less than one month
3=One to three months
4=More than three months, but less than one year
5=One year or longer
2.9 Zip Code of Last Permanent Address
1=Full Zip Code Recorded
8=Don’t Know
9=Refused
2.10 Program Entry Date
Month/Day/Year: __/__/____
2.11 Program Exit Date
Month/Day/Year: __/__/____
2.12 Unique Person Identification Number
A PIN must be created, but there is no required format as long as there is a single
unique PIN for every client served and it contains no personally identifying
information.
2.14 Household Identification Number
A Household ID number must be created, but there is no required format as long as the
number allows identification of clients that receive services as a household.
___________________________________________________________________________________________
)
Previous editions are obsolete
Page 24
form HUD-40110-C (Expiration Date: 12/31/2010
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