"Hmis Data Entry Form" - North Dakota

Hmis Data Entry Form is a legal document that was released by the North Dakota Department of Commerce - a government authority operating within North Dakota.

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HMIS Data Entry Form
Section 1: Demographics (required for ALL clients, secondary race is optional)
Client Name:
Alias:
SSN: ______ / ______ / __________
 Female
 Transgendered (Female to Male)
 Refused
 Other
DOB:
_____ / _____ / __________
Gender:
Month
Day
Year
 Male
 Transgendered (Male to Female)
 Don’t Know
 White
 Black/African-American
 Asian
 Does not know
Primary Race:
 American Indian/Alaskan Native
 Native Hawaiian/Other Pacific Islander
 Other
 Refused
 White
 Black/African-American
 Asian
 Does not know
Secondary Race:
 American Indian/Alaskan Native
 Native Hawaiian/Other Pacific Islander
 Other
 Refused
 Non-Hispanic/Non-Latino
 Hispanic/Latino
 Don’t Know
 Refused
Ethnicity:
Section 2: Household (Household Type required for ALL clients)
 Two Parent Family
 Grandparent(s) & Child
 Other
 Couple with No Children
Household Type:
 Foster Parents
 Non-custodial Caregiver(s)
 Single Parent
Name
Age
Relationship to Head of Household
Joined Household Date
1.
self
(program entry date)
2.
(program entry date)
3.
(program entry date)
4.
(program entry date)
5.
(program entry date)
6.
(program entry date)
7.
(program entry date)
8.
(program entry date)
Section 3: Release of Information
 Yes
 No
Release Granted:
Start Date:
(program entry date)
End Date:
_____ / _____ / __________
Month
Day
Year
Section 4: Program Entry/Exit (required for ALL clients)
Type:
Basic
Basic Center Program Entry/Exit
HUD
Quick Call
VA
Transitional Living Program Entry/Exit
PATH
Standard
Start Date:
_____ / _____ / __________
End Date:
_____ / _____ / __________
Month
Day
Year
Month
Day
Year
Section 5: Case Manager & Case Plans
Case Manager
Title
Phone
Email
Start Date:
_____ / _____ / __________
End Date:
_____ / _____ / __________
Month
Day
Year
Month
Day
Year
Goal (classification & type)
Overall Status
Date Goal Set
1.
(program entry date)
2.
(program entry date)
3.
(program entry date)
4.
(program entry date)
5.
(program entry date)
Section 6: Housing Status (required for ALL clients)
 Literally Homeless
 Imminently losing their housing
 Unstably housed and at-risk of losing their housing
Housing Status:
 Stably housed
 Don’t know
 Refused
 Category 1
 Category 2
 Category 3
 Other (ineligible)
Category of Permanent Housing:
 Yes
 No
 Don’t know
 Refused
Formerly Chronically Homeless?
 Yes
 No
Is Client Chronically Homeless?
 < 30% AMI
 30-50% AMI
 > 50% AMI (ineligible)
HH Income as a % of Area Median Income (AMI)?
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HMIS Data Entry Form
Section 1: Demographics (required for ALL clients, secondary race is optional)
Client Name:
Alias:
SSN: ______ / ______ / __________
 Female
 Transgendered (Female to Male)
 Refused
 Other
DOB:
_____ / _____ / __________
Gender:
Month
Day
Year
 Male
 Transgendered (Male to Female)
 Don’t Know
 White
 Black/African-American
 Asian
 Does not know
Primary Race:
 American Indian/Alaskan Native
 Native Hawaiian/Other Pacific Islander
 Other
 Refused
 White
 Black/African-American
 Asian
 Does not know
Secondary Race:
 American Indian/Alaskan Native
 Native Hawaiian/Other Pacific Islander
 Other
 Refused
 Non-Hispanic/Non-Latino
 Hispanic/Latino
 Don’t Know
 Refused
Ethnicity:
Section 2: Household (Household Type required for ALL clients)
 Two Parent Family
 Grandparent(s) & Child
 Other
 Couple with No Children
Household Type:
 Foster Parents
 Non-custodial Caregiver(s)
 Single Parent
Name
Age
Relationship to Head of Household
Joined Household Date
1.
self
(program entry date)
2.
(program entry date)
3.
(program entry date)
4.
(program entry date)
5.
(program entry date)
6.
(program entry date)
7.
(program entry date)
8.
(program entry date)
Section 3: Release of Information
 Yes
 No
Release Granted:
Start Date:
(program entry date)
End Date:
_____ / _____ / __________
Month
Day
Year
Section 4: Program Entry/Exit (required for ALL clients)
Type:
Basic
Basic Center Program Entry/Exit
HUD
Quick Call
VA
Transitional Living Program Entry/Exit
PATH
Standard
Start Date:
_____ / _____ / __________
End Date:
_____ / _____ / __________
Month
Day
Year
Month
Day
Year
Section 5: Case Manager & Case Plans
Case Manager
Title
Phone
Email
Start Date:
_____ / _____ / __________
End Date:
_____ / _____ / __________
Month
Day
Year
Month
Day
Year
Goal (classification & type)
Overall Status
Date Goal Set
1.
(program entry date)
2.
(program entry date)
3.
(program entry date)
4.
(program entry date)
5.
(program entry date)
Section 6: Housing Status (required for ALL clients)
 Literally Homeless
 Imminently losing their housing
 Unstably housed and at-risk of losing their housing
Housing Status:
 Stably housed
 Don’t know
 Refused
 Category 1
 Category 2
 Category 3
 Other (ineligible)
Category of Permanent Housing:
 Yes
 No
 Don’t know
 Refused
Formerly Chronically Homeless?
 Yes
 No
Is Client Chronically Homeless?
 < 30% AMI
 30-50% AMI
 > 50% AMI (ineligible)
HH Income as a % of Area Median Income (AMI)?
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HMIS Data Entry Form
Section 7: Client Income (required for ALL clients)
 Yes
 No
 Don’t know
 Refused
Income received from any source in past 30 days?
Income Source (use number
Receiving Income
from list below)
Last 30 Day Income
Source
Start Date
End Date
_____ / _____ / __________
 Yes
 No
$
(program entry date)
Month
Day
Year
If other, please specify:
_____ / _____ / __________
 Yes
 No
$
(program entry date)
Month
Day
Year
If other, please specify:
_____ / _____ / __________
 Yes
 No
$
(program entry date)
Month
Day
Year
If other, please specify:
_____ / _____ / __________
 Yes
 No
$
(program entry date)
Month
Day
Year
If other, please specify:
Total Monthly Income: $
Income Source
#
Source
#
Source
1
Alimony or Other Spousal Support
13
Retirement
2
Annuities
14
Retirement Disability
3
Child Support
15
Retirement Income From Social Security
4
Contributions from Other People
16
Self Employment Wages
5
Dividends (Investments)
17
SSDI
6
Earned Income
18
SSI
7
General Assistance
19
State Disability
8
No Financial Resources
20
TANF
9
Other
21
Unemployment Insurance
10
Pension From a Former Job
22
Veteran’s Disability Payment
11
Private Disability Insurance
23
Veteran’s Pension
12
Rental Income
24
Worker’s Compensation
 Yes
 No
 Refused
Non-cash benefit received from any source in past 30 days?
Don’t know
Non-cash benefit Source (use
number from list below)
Receiving Income Source
Start Date
End Date
_____ / _____ / __________
 Yes
 No
(program entry date)
Month
Day
Year
If other, please specify:
_____ / _____ / __________
 Yes
 No
(program entry date)
Month
Day
Year
If other, please specify:
_____ / _____ / __________
 Yes
 No
(program entry date)
Month
Day
Year
If other, please specify:
_____ / _____ / __________
 Yes
 No
(program entry date)
Month
Day
Year
If other, please specify:
Non-cash benefit source
#
Source
#
Source
1
Supplemental Nutrition Assistance Program (Food Stamps)
11
TANF Child Care Services
2
MEDICAID
12
TANF Transportation Services
3
MEDICARE
13
Other – TANF – Funded Services
4
SCHIP
14
Section 8, Public Housing or rental assistance
5
Special Supplemental Nutrition Program for WIC
15
Other Source
6
Veteran’s Administration (VA) Medical Services
16
Temporary rental assistance
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HMIS Data Entry Form
Section 8: Disability (required for ALL clients)
 Yes
 No
 Don’t know
 Refused
Do you have a disability of long duration?
Disability
Type (use
Condition is going to
If yes, Currently receiving
number
Disability determination
End Date
be long term?
services or treatment
from list
below):
 Yes
 No
 Yes
 No
_____ / _____ / __________
 Yes
 No
1.
 Don’t Know
 Refused
 Don’t Know
 Refused
Month
Day
Year
If other, please specify:
 Yes
 No
 Yes
 No
_____ / _____ / __________
 Yes
 No
2.
 Don’t Know
 Refused
 Don’t Know
 Refused
Month
Day
Year
If other, please specify:
 Yes
 No
 Yes
 No
_____ / _____ / __________
 Yes
 No
3.
 Don’t Know
 Refused
 Don’t Know
 Refused
Month
Day
Year
If other, please specify:
 Yes
 No
 Yes
 No
_____ / _____ / __________
 Yes
 No
4.
 Don’t Know
 Refused
 Don’t Know
 Refused
Month
Day
Year
If other, please specify:
Disability Type
#
Type
#
Type
1
Alcohol Abuse (HUD 40118)
8
HIV/AIDS (HUD 40118)
2
Both alcohol and drug abuse (HUD 40118)
9
Mental Health Problem (HUD 40118)
3
Chronic Health Condition
10
Other
4
Developmental (HUD 40118)
11
Physical (HUD 40118)
5
Drug Abuse (HUD 40118)
12
Physical/Medical (HUD 40118)
6
Dual Diagnosis
13
Vision Impaired
7
Hearing Impaired
Section 9: Domestic Violence (required for all adults 18+) & Living Situation (required for ALL clients)
 Yes
 No
 Don’t know
 Refused
Domestic violence victim/survivor?
Extent of Domestic Violence (how long did it occur)?
 Don’t Know
Type of Living Situation?
 Emergency shelter, including hotel or motel paid for with emergency shelter voucher
 Foster care home or foster care group home
 Hospital (non-psychiatric
 Hotel or motel paid for without emergency shelter voucher
 Jail, prison, or juvenile detention facility
 Other
 Owned by client, no housing subsidy
 Owned by client, with housing subsidy
 Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO Mod Rehab)
 Place not meant for habitation inclusive of ‘non-housing service site(outreach programs only)’(HUD)
 Psychiatric hospital or other psychiatric facility
 Refused
 Rental by client, no housing subsidy
 Rental by client, with housing subsidy
 Rental by client with VASH housing subsidy
 Safe Haven
 Staying or living in a family member’s room, apartment, or house
 Staying or living in a friend’s room, apartment, or house
 Don’t Know
 Refused
Length of stay:
Zip code of Last Permanent Address:
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HMIS Data Entry Form
Section 10: Military Information (Veteran Status required for ALL clients, rest of the section required for all adults 18+)
 Yes
 No
 Don’t know
 Refused
U.S. Military Veteran?
Months Served on Active Duty:
 Army
 Air Force
 Navy
 Marines
 Other
 Don’t Know
 Refused
Military Branch:
 Persian Gulf Era (August 1991 – September 10, 2001)
Military Service Era?
 Post Vietnam (May 1975 – July 1991)
 Vietnam Era ( August 1964 – April 1975)
 Between Korean and Vietnam War (February 1955 – July 1964)
 Korean War (June 1950 – January 1955)
Start Date:
 Between WWII and Korean War (August 1947 – May 1950)
(program entry date)
 World War II (September 1940 – July 1947)
 September 11, 2001 – present
End Date:
 Don’t Know
______/______/____________
 Refused
 Yes
 No
 Don’t know
 Refused
Did You Serve in a War Zone?
Months Served in a War Zone:
 Europe
 North Africa
 Vietnam
 Loas & Cambodia
 South China Sea
 China, Burma, India
War Zone:
 Korea
 South Pacific
 Persian Gulf
 Afghanistan
 Other
 Don’t know
 Refused
 Yes
 No
 Don’t Know
 Refused
Received hostile or friendly fire in a War Zone:
Start Date: Date of program entry
End Date: ______/______/______
Month
Day
Year
(Complete this portion of the assessment ONLY for the Head of Household (or a single person) assessment.)
 Yes
 No
Household with one or more female veteran?
 Yes
 No
Household earns less than 30% AMI
 Yes
 No
Very low-income Veteran household which is homeless & scheduled to become residence of permanent housing w/in
90 days
 Yes
 No
Have exited permanent housing within the previous 90 days to seek other housing that is responsive to their needs
and preferences
 Yes
 No
Household is residing in permanent housing
Answer the following for each adult in the household
 Yes
 No
Serve in Iraq or Afghanistan?
 Yes
 No
Receiving VA Health Care and/or Other VA Benefits
 Yes
 No
Roommate(s) with separate lease agreements?
Section 11: Emergency Contacts
Contact’s Name
Phone
Second Phone
Relation to Client
1.
2.
3.
Section 12: Needs
Need (use
Amount if
number from
Date of Need
Need Status
Outcome of Need
Notes
Financial
list below):
1.
(program entry date)
$
2.
(program entry date)
$
3.
(program entry date)
$
4.
(program entry date)
$
5.
(program entry date)
$
6.
(program entry date)
$
Need Type
#
Type
#
Type
1
Case/Care Management
5
Street Outreach Program
2
Moving Expense Assistance
6
Utility Deposit Assistance
3
Rental Deposit Assistance
7
Utility Service Payment Assistance
4
Rent Payment Assistance
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HMIS Data Entry Form
Section 13: Services (HPRP Housing Relocation & Stabilization Service Provided required for HUD funded programs)
Service (use
Service
# of
Cost per
Funding
number from
Start Date
Unit Type
Costs
Units
Unit
Source
End Date
list below):
______/______/______
1.
(program entry date)
$
Month
Day
Year
HPRP Housing Relocation & Stabilization Service Provided
 Outreach & engagement
 Legal Services
Case management
Housing search & placement
Credit repair
HPRP Financial Assistance Type
 Rental assistance
 Security deposits
 Utility deposits
 Utility payments
 Moving cost assistance
 Motel & hotel vouchers
Projected Follow-up Date:
______/______/______
Completed Follow Up Date
______/______/______
Month
Day
Year
Month
Day
Year
______/______/______
2.
(program entry date)
$
Month
Day
Year
HPRP Housing Relocation & Stabilization Service Provided
 Outreach & engagement
 Legal Services
Case management
Housing search & placement
Credit repair
HPRP Financial Assistance Type
 Rental assistance
 Security deposits
 Utility deposits
 Utility payments
 Moving cost assistance
 Motel & hotel vouchers
Projected Follow-up Date:
______/______/______
Completed Follow Up Date
______/______/______
Month
Day
Year
Month
Day
Year
______/______/______
3.
(program entry date)
$
Month
Day
Year
HPRP Housing Relocation & Stabilization Service Provided
 Outreach & engagement
 Legal Services
Case management
Housing search & placement
Credit repair
HPRP Financial Assistance Type
 Rental assistance
 Security deposits
 Utility deposits
 Utility payments
 Moving cost assistance
 Motel & hotel vouchers
Projected Follow-up Date:
______/______/______
Completed Follow Up Date
______/______/______
Month
Day
Year
Month
Day
Year
______/______/______
4.
(program entry date)
$
Month
Day
Year
HPRP Housing Relocation & Stabilization Service Provided
 Outreach & engagement
 Legal Services
Case management
Housing search & placement
Credit repair
HPRP Financial Assistance Type
 Rental assistance
 Security deposits
 Utility deposits
 Utility payments
 Moving cost assistance
 Motel & hotel vouchers
Projected Follow-up Date:
______/______/______
Completed Follow Up Date
______/______/______
Month
Day
Year
Month
Day
Year
______/______/______
5.
(program entry date)
$
Month
Day
Year
HPRP Housing Relocation & Stabilization Service Provided
 Outreach & engagement
 Legal Services
Case management
Housing search & placement
Credit repair
HPRP Financial Assistance Type
 Rental assistance
 Security deposits
 Utility deposits
 Utility payments
 Moving cost assistance
 Motel & hotel vouchers
Projected Follow-up Date:
______/______/______
Completed Follow Up Date
______/______/______
Month
Day
Year
Month
Day
Year
______/______/______
6.
(program entry date)
$
Month
Day
Year
HPRP Housing Relocation & Stabilization Service Provided
 Outreach & engagement
 Legal Services
Case management
Housing search & placement
Credit repair
HPRP Financial Assistance Type
 Rental assistance
 Security deposits
 Utility deposits
 Utility payments
 Moving cost assistance
 Motel & hotel vouchers
Projected Follow-up Date:
______/______/______
Completed Follow Up Date
______/______/______
Month
Day
Year
Month
Day
Year
Service Type
#
Type
#
Type
1
Case/Care Management
5
Street Outreach Program
2
Moving Expense Assistance
6
Utility Deposit Assistance
3
Rental Deposit Assistance
7
Utility Service Payment Assistance
4
Rent Payment Assistance
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