CLARITY HMIS: VA SERVICES INTAKE FORM (HUD VASH, SSVF, GPD) Use block letters for text and bubble in the appropriate circles. Please complete a separate form for each household member. PROJECT START DATE​ Clients] Month Day Year SOCIAL SECURITY NUMBER​ Clients] QUALITY OF SOCIAL SECURITY ○ Full SSN reported ○ Client doesn’t know ○ Client refused ○ Approximate or partial SSN reported ○ Data not collected CURRENT NAME Clients] Last First Middle Suffix QUALITY OF CURRENT NAME ○ Full name reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client refused ○ Data not collected DATE OF BIRTH​ Clients] Age: Day Year QUALITY OF DATE OF ○ Full DOB reported ○ Client doesn’t know ○ Approximate or partial DOB reported ○ Client refused ○ Data not collected GENDER​ Clients] ○ Female ○ Client doesn’t know ○ Male ○ Client refused ○ Female (MTF or Male to Female) ○ Data not collected [All [All
○ 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 ○ Client does not know Asian ○ Client refused Black/African American ○ Data Not Collected Hawaiian or Other Pacific Islander White/Caucasian ETHNICITY​ Clients] ○ ○ Client does not know ○ Client refused ○ Hispanic/Latino ○ Data Not Collected ○ 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Persian Gulf War (Desert Storm) ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Afghanistan (Operation Enduring Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected
Theater of Operations: Iraq (Operation Iraqi Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Iraq (Operation New Dawn) ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Branch of the Military ○ Army ○ Coast Guard ○ Air Force ○ Client doesn’t know ○ Navy ○ Client refused ○ Marines ○ Data not collected Discharge Status ○ Honorable ○ Dishonorable ○ General under honorable conditions ○ Uncharacterized ○ Other than honorable conditions (OTH) ○ Client know ○ Client refused ○ Bad Conduct ○ Data not collected RELATIONSHIP TO HEAD OF HOUSEHOLD Client Households] ○ Self ○ Head of household - other relation to member ○ Head of household’s child ○ Head of household’s spouse or partner ○ member CLIENT LOCATION [only if multiple CoC’s] ______________________ ZIP CODE OF LAST PERMANENT ADDRESS Clients] IN PERMANENT HOUSING Housing Projects, for Heads of Households] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING Housing Move-in Date ____/____/__________
CONNECTION WITH SOAR of Households and Adults, not required for HUD VASH or GPD] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected LAST GRADE COMPLETED of Household & Adults,not required for GPD] ○ Less than Grade 5 ○ Grades 5-6 ○ Grades 7-8 ○ Grades 9-11 ○ Grade 12 ○ School does not have grade levels ○ GED ○ Some college ○ Associate’s Degree ○ Bachelor's degree ○ Graduate Degree ○ Vocational certification ○ Client doesn't know ○ Data not collected ○ Client refused EMPLOYMENT STATUS of Household, Adults, HUD-VASH OTH only] Employed ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected If “Yes” for employed – Type of employment ○ ○ Seasonal/sporadic (including day ○ If “No” for employed – Why not employed ○ Looking for work ○ Not looking for work ○ Unable to work GENERAL HEALTH STATUS of Household, Adults, HUD-VASH OTH only] ○ Excellent ○ Poor ○ Very good ○ Client doesn’t know ○ Good ○ Client refused ○ Fair ○ Data not collected LAST PERMANENT ADDRESS of Household and Adults, not required for GPD] Street Address City State Zip Code QUALITY OF ADDRESS ○ Full address reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client refused ○ Data not collected [Head
Any Veteran in household served in Iraq or Afghanistan? ○ Yes ○ Female Veteran? ○ Yes ○ HP applicant points (integer) _____________ Grantee targeting threshold (integer) _______________ USE OF OTHER CRISIS SERVICES: [RRH/HP] programs of Household / Adults] Number of Visits to an Emergency Room in the Past Year? ○ 0 ○ Client doesn’t know ○ 1 - 2 ○ Client refused ○ 3 - 5 ○ Data not collected ○ 6 - 10 ○ 11 – 20 ○ 20 or More Approximate Number of Nights in Jail/Prison in the Past Year? ○ 0 ○ Client doesn’t know ○ 1 - 2 ○ Client refused ○ 3 - 5 ○ Data not collected
○ 6 - 10 ○ 11 – 20 ○ 20 or More Approximate Number of Spent in an Inpatient Medical Facility in the Past Year? ○ 0 ○ Client doesn’t know ○ 1 - 2 ○ Client refused ○ 3 - 5 ○ Data not collected ○ 6 - 10 ○ 11 – 20 ○ 20 or More PRIMARY LANGUAGE Clients, optional] ○ English ○ Mandarin ○ Spanish ○ Tagalog ○ Vietnamese ○ ○ Unknown Signature of applicant stating all information is true and correct Date