Apr Universal Data Elements

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New Hampshire Continua of Care – APR
-
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)

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