New Hampshire Continua of Care – APR
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Universal Data Elements (UDE) Form for HMIS
Refer to the HUD HMIS Data Standards – March 2010 for an explanation of the data elements. This document can be
found at
Date Completed: __ __/ __ __/ __ __ __ __
Intake Interviewer Name: ______________________________________
Client ID Number: ________________________ Case Manager Name: __________________________________________
Program: _____________________________________________
Location:______________________________________
Program Entry Date: ______/______/_________
First, MI, Last Name, Suffix:
Alias:
Full SSN Reported
Does Not Know or Does Not Have SSN
SSN:
-
-
SSN Type: Partial SSN Reported
Refused
Full DOB Reported
Don’t Know
Date of Birth:
/
/
Date of Birth Type: Approximate or Partial DOB Reported Refused
Gender: Female Male Transgender Female to Male Transgender Male to Female Other Don’t Know Refused
Primary Race:
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Don’t Know
Asian
White
Refused
Black or African American
Secondary Race:
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Don’t Know
Asian
White
Refused
Black or African American
Ethnicity (choose one):
Hispanic/Latino
Non-Hispanic/Non-Latino
Don’t Know
Refused
Do you have a disability of long duration?
Yes
No
Don’t Know
Refused
This form can be found on
Page 1 of 1
Form– Rev. 7/2012
APR Universal Data Elements (UDE)