○ Male ○ Client refused ○ Trans Female (MTF or Male to Female) ○ Data not collected ○ Trans Male (FTM or Female to Male) ○ Gender Non-Conforming (i.e. not exclusively male or female) RACE all applicable) Clients] ○ American Indian or Alaskan Native ○ White/Caucasian ○ Asian ○ Client does not know ○ Black/African American ○ Client refused ○ Hawaiian or Other Pacific Islander ○ Data Not Collected ETHNICITY​ Clients] ○ ○ Client does not know ○ Client refused ○ Hispanic/Latino ○ Data Not Collected ○ Other VETERAN STATUS​ Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO VETERAN STATUS Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Korean War ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Vietnam War ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Persian Gulf War (Desert Storm) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Afghanistan (Operation Enduring Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client refused
○ Two Times ○ Client refused ○ Three Times ○ Data not collected ○ Four or More Times Total Number of Months homeless on the streets, ES, or Safe Haven in the last 3 years ○ One (this time is the first month) ○ Client doesn’t know ○ months (specify number of months): ________ ○ Client refused ○ More than 12 months ○ Data not collected WHEN CLIENT WAS ENGAGED Date of Engagement: ____/____/__________ PATH STATUS Client Became Enrolled in PATH ○ No ○ Yes Date of Status Determination ____/____/__________ IF “NO” TO ENROLLED IN PATH Reason Not Enrolled ○ Client was found ineligible for PATH ○ Client was not enrolled for other reason(s) DISABLING CONDITION Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected PHYSICAL DISABILITY Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO PHYSICAL DISABILITY – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected DEVELOPMENTAL DISABILITY Clients] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY Expected to substantially impair ability to live independently ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION Clients] ○ No ○ Client know
○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected HIV-AIDS Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO HIV-AIDS – SPECIFY Expected to substantially impair ability to live independently ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected MENTAL HEALTH PROBLEM Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO MENTAL HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected SUBSTANCE ABUSE PROBLEM Clients] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client doesn’t know ○ Client refused ○ Drug abuse ○ Data not collected IF “ALCOHOL “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE” – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source ○ Alimony and other spousal support ○ Child support ○ Pension or retirement income from former job ○ Earned Income ○ Retirement Income from Social Security ○ General Assistance (GA)