Demographics (In HMIS: Use Clientpoint Search and Client Profile Tab)
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HMIS Client ID # LTH Entry Form for HMIS: SINGLE CLIENTS: Also use for additional household members who join later
Data Collection HMIS Tips: Instructions: Use the General HMIS Instructions & your program’s (funder) Supplemental User Guide for complete data entry Underlined terms have instruction. definitions provided at EDA to Entry provider. Set backdate when prompted after searching for a client. Date should match project start date. hmismn.org. Please print a If information is missing, follow-up with the client or staff person responsible for gathering information to complete the copy to have available. missing information. DO NOT enter “don’t know” or “refused” unless the Client doesn’t know or refused an answer.
Demographics (in HMIS: use ClientPoint Search and Client Profile Tab)
Client Information Name: First: Middle: Last: Suffix: Name Data Quality (Use DQ answer choices): Data Quality (DQ) Answer Alias: (add SHARED if client consents to statewide data sharing) Choices: Social Security Number (SSN): SSN Data Quality (Use DQ answer choices): Full Approx.- Approximate or Partial U.S. Military Veteran: Has the client ever served in the military? (18+ only) Yes No DK R NC DK- Client doesn’t know R- Client refused Date of Birth (D.O.B.)*: _____/_____/_____D.O.B. Type (Use DQ answer choices): NC- Data not collected *(D.O.B. Required for ALL clients. If client doesn’t know or refuses to provide DOB, use 01/01/(estimated year of birth) as the birth date. (DK, R, and NC should rarely be used) Gender: Race: (Select up to 5 races) Ethnicity: Female American Indian or Alaskan Native Non-Hispanic/Non-Latino Male Asian Hispanic Latino Trans Female (MTF or Male to Female) Black or African American Client doesn’t know Trans Male (FTM or Female to Male) Gender Non-Conforming (i.e. not Native Hawaiian or Other Pacific Islander Client refused exclusively male or female) White Data not collected Client doesn’t know Client doesn’t know Hispanic/Latino clients must also choose a race (often white). Client refused Client refused Data not collected Data not collected If client does not identify with any race options above, select “Client refused.” Agency’s Client ID # (if your agency assigns a unique client ID #) Date of ROI Consent: _____/_____/_____ (only enter if client consents to statewide data sharing - never override a previously entered date) If client is joining a household later, please note head of household here:
LTH Entry Form for Single Clients 1 of 9 hmismn.org Last updated 2/28/2018 Program Entry (in HMIS: use Entry/Exit Tab)
1. Provider: 2. Type: Basic 3. Project Start Date: _____ / _____ / _____ (Month/Day/Year)
MN: Ending LTH All-Inclusive Assessment (IN HMIS: Entry/Exit Tab)
Data Collection Instructions HMIS Tips All questions refer to the day before project start date. Add Entry/Exit. Confirm Provider, Type, and Project Start Date. Save & Continue. Entry Assessment will appear in a pop-up window. Section 1. Client Information
Relationship to Head of Household Self (single/head of household) Head of household’s spouse or partner Other: non-relation member Head of household’s child Head of household’s other relation Data not collected member
Does the client have a disability of long duration? Yes No Client doesn’t know Client refused Data not collected Documentation is not required to answer “yes.” Clients can answer “yes” even if they have never been officially diagnosed with a disability (see definitions). Alcohol/drug abuse is considered a disability of long duration.
a. Did you serve in the United States Armed Forces? (which includes the Army, Navy, Air Force, Marine Corps, and Coast Guard)? (18+ only) Yes No DK R NC (Same as question on Client Profile tab; this question will not be on Entry Assessment, it will only be on profile tab.) ) b. Did you serve on Active Duty, or in No Yes, National Guard Both Guard and Reserves the National Guard or Reserves? Yes, Active Duty (regardless of Guard and Reserve answers) Yes, Reserves DK R NC (18+ only) If yes to questions a or b, answer questions c-i. If no, skip to next question series. c. If Guard or Reserve: Were you ever called to Active Duty as a Yes No DK R NC member of the National Guard or as a Reservist? d. Did you enter Active Duty before 9/7/1980? Yes No DK R NC e. For approximately how many months did you serve? ______(# of months) Approximate answers OK Honorable or under honorable conditions Dishonorable f. What kind of discharge did you have? Other than honorable, but not dishonorable DK R NC g. Are you receiving VA disability pay? Yes No DK R NC h. Does client have military disability status rating? Yes No i. Has the client been referred to the Homeless Veteran Registry? Yes No DK R NC *The Homeless Veteran Registry can be found here: https://mn.gov/mdva/resources/homelessnessandprevention/homelessveteranregistry.jsp Anyone who served in the U.S. Armed Forces, Reserves, or National Guard can join the Registry, regardless of the type of discharge. If you are a Veteran and choose to join, a team of housing and service professionals will work together to help you access housing and services that meet your needs. Participation is voluntary. You do not have to join and choosing not to participate will not affect your eligibility for services.
LTH Entry Form for Single Clients 2 of 9 hmismn.org Last updated 2/28/2018 a. Domestic violence victim/survivor b. If yes for domestic violence c. If yes for domestic violence (ever) victim/survivor, when experience victim/survivor, are you currently fleeing? Yes occurred Yes No Within the past 3 months No DK R NC 3-6 months ago DK R NC 6-12 months ago More than 1 year ago DK R NC Are you or have you ever been in foster care? (Clients 24 or younger) Yes No Client doesn’t know Client refused Data not collected
MARSS Number: (Required only for Highly Mobile Student Programs. Must be completed for each child who attends school.) a. Covered by Health Insurance Yes No Client doesn’t know Client refused Data not collected HMIS Tips: Enter health insurance using the HUD Verification tool. Start date is the project start date. A response is required for each health insurance type (select Yes/No/NC). b. Health Insurance MEDICAID Yes No NC Health Insurance obtained through COBRA Yes No NC MEDICARE Yes No NC Private Pay Health Insurance Yes No NC State Children’s Health Insurance Program Yes No NC State Health Insurance for Adults Yes No NC Veteran’s Administration (VA) Medical Services Yes No NC Indian Health Services Program Yes No NC Employer-Provided Health Insurance Yes No NC Other Yes No NC
HMIS Tips: Enter disabilities using HUD Verification. Disability Determination is “Yes” if the client has the disability during the time period. Start date is the project start date. (HUD)=HUD-approved source. Non-HUD-approved disabilities must be entered using the “Add” button. If Yes, Expected to be of long–continued and indefinite Start Disability Type Disability Determination duration and substantially impairs ability to live Date independently? e Mental Health Problem (HUD) Yes No DK R NC t Yes No DK R NC a
Physical (HUD) Yes No DK R NC D Yes No DK R NC
t Developmental (HUD) r Yes No DK R NC a Yes No DK R NC t
Chronic Health Condition (HUD) S Yes No DK R NC Yes No DK R NC t Alcohol Abuse (HUD) Yes No DK R NC c Yes No DK R NC e j
Drug Abuse (HUD) o Yes No DK R NC r Yes No DK R NC Both Alcohol and Drug Abuse (HUD) Yes No DK R NC P Yes No DK R NC HIV/AIDS (HUD) Yes No DK R NC Yes No DK R NC LTH Entry Form for Single Clients 3 of 9 hmismn.org Last updated 2/28/2018 Traumatic Brain Injury Yes No DK R NC Yes No DK R NC Hearing Impaired Yes No DK R NC Yes No DK R NC Vision Impaired Yes No DK R NC Yes No DK R NC Other (Specify): ______ Yes No DK R NC Yes No DK R NC
Section 2. Resources a. Income from any source Yes No Client doesn’t know Client refused Data not collected HMIS Tips: Enter income using the HUD Verification tool. Start date is the project start date. “Receiving income source” will remain “yes,” even if income ends. (HUD)=HUD-approved source. Non-HUD-approved income sources can be entered using the “Add” button. b. Monthly Income: Monthly amount Monthly amount VA Non-Service Connected Disability Pension Earned Income (HUD) Y N NC $ Y N NC $ (HUD) Pension or retirement income from another job Unemployment Insurance (HUD) Y N NC $ Y N NC $ (HUD) SSI (HUD) Y N NC $ Child Support (HUD) Y N NC $ SSDI (HUD) Y N NC $ Alimony or Other Spousal Support (HUD) Y N NC $ VA Service Connected Disability Compensation Y N NC $ Other (specify) (HUD) ______ Y N NC $ (HUD) Private Disability Insurance (HUD) Y N NC $ Contributions From Other People Y N NC $ Worker’s Compensation (HUD) Y N NC $ Interest, Dividends, & Annuities Y N NC $ TANF (HUD) Y N NC $ MSA/Minnesota Supplemental Aid Y N NC $ General Assistance (HUD) Y N NC $ Student Grant/Scholarship Y N NC $ Retirement Income From Social Security (HUD) Y N NC $ Tribal Funds Y N NC $ c. Total monthly income: $______.00 a. Non-cash benefit from any source Yes No Client doesn’t know Client refused Data not collected HMIS Tips: Enter non-cash benefits using the HUD Verification tool. Non-HUD-approved non-cash benefit sources must be entered using the “Add” button. Start date is the project start date. “Receiving benefit” will remain “Yes” even if benefit ends. Do not record an amount for non-cash benefits in HMIS. b. Non-Cash Benefits Supplemental Nutrition Assistance Program (Food Stamps) Yes No NC TANF Transportation services (HUD) Yes No NC (HUD) Special Supplemental Nutrition Program for WIC (HUD) Yes No NC Other TANF-Funded services (HUD) Yes No NC TANF Child Care Services (HUD) Yes No NC Other source (HUD) ______Yes No NC
LTH Entry Form for Single Clients 4 of 9 hmismn.org Last updated 2/28/2018 Section 3. Housing Situation
Extent of homelessness by Minnesota’s definition on the day before project start date: Not currently homeless First time homeless AND less than one year without home Multiple times homeless, but not meeting long-term homeless definition Long term: homeless at least 1 year OR at least 4 times in the past 3 years
Leave any of these? (0-3 months ago) Did the client leave any of the places listed below in the last 3 months before project start date? (If client has left more than one place in the last 3 months, please select the place the client left most recently.) Yes (If yes, select the answers below) No (if no, continue to the next question) Adoptive Home (from foster care system) Foster Home (youth only) Juvenile Detention Center County Jail or Workhouse State or Federal Prison Mental Health Treatment Facility or Hospital Drug or Alcohol Treatment Facility Combined MI/CD Treatment Facility Group Home Half-way House Residence for People with Physical Disabilities Client doesn’t know Client refused Data not collected
Leave any of these? (over 3 months ago, up to 6 months ago) Did the client leave any of the places listed below over 3 months ago, up to 6 months ago? (If client has left more than one place in that time period, please select the place the client left most recently.) Yes (If yes, select the answers below) No (if no, continue to the next question) Adoptive Home (from foster care system) Foster Home (youth only) Juvenile Detention Center County Jail or Workhouse State or Federal Prison Mental Health Treatment Facility or Hospital Drug or Alcohol Treatment Facility Combined MI/CD Treatment Facility Group Home Half-way House Residence for People with Physical Disabilities
LTH Entry Form for Single Clients 5 of 9 hmismn.org Last updated 2/28/2018 Client doesn’t know Client refused Data not collected
A. Type of Residence on Night Before Project Start Date (Pick ONLY ONE under Literally Homeless, Institutional, OR Transitional and Permanent Housing) Literally Homeless Situation Institutional Situation Transitional and Permanent Housing Situation Place not meant for Foster care home or foster care Hotel or motel paid for without Rental by client, with other ongoing habitation (a vehicle, group home emergency shelter voucher housing subsidy (including RRH) abandoned building, Hospital or other residential non- Owned by client, no ongoing Residential project or halfway house with bus/train/subway psychiatric medical facility housing subsidy no homeless criteria station/airport, or Jail, prison, or juvenile detention Owned by client, with ongoing Staying or living in a family member's anywhere outside) facility housing subsidy room, apartment or house Emergency shelter, Long-term care facility or nursing Permanent Housing (other than Staying or living in a friend's room, including hotel or motel home RRH) for formerly homeless apartment or house paid for with emergency persons shelter voucher Psychiatric hospital or other Transitional housing for homeless persons psychiatric facility Rental by client, no ongoing (including homeless youth) Safe Haven Substance abuse treatment facility housing subsidy Client doesn’t know Interim Housing or detox center Rental by client, with VASH Client refused subsidy Data not collected Rental by client, with GPD TIP subsidy
B. Length of Stay at B. Length of Stay at Prior Living B. Length of Stay at Prior Living Situation (Transitional and permanent Prior Living Situation Situation (Institutional situation) situation) (Literally homeless situation) One night or less One night or less One night or less Two to six nights Two to six nights Two to six nights One week or more, but less than One week or more, but less than one month One week or more, but one month One month or more, but less than 90 days less than one month One month or more, but less than 90 days or more, but less than one year One month or more, but 90 days One year or longer less than 90 days 90 days or more, but less than one Client doesn’t know 90 days or more, but less year Client refused than one year One year or longer Data not collected One year or longer Client doesn’t know Client doesn’t know Client refused Client refused LTH Entry Form for Single Clients 6 of 9 hmismn.org Last updated 2/28/2018 Data not collected Data not collected
Skip C. Move to D. C. If selected an unshaded response, you are done with this series of questions and should move to the next question “How long since client […]?” on the next page. If selected one of the shaded response (indicating less than 90 days in institutional setting, or less than 7 days in transitional or permanent housing), on the night before did you stay on the streets or in emergency shelter? □ Yes (Move to D) □ No (Done. Move to the next question “How long since client […]?” on the next page.)
D. Approximate date homelessness started _____/_____/______E. Number of times the client has been on the streets or in emergency shelter in the past three years (including today) □ 1 time □ 2 times □ 3 times □ 4 or more times □ Client doesn’t know □ Client refused F. Total number of months homeless on the street or in emergency shelter in the past 3 years □ 1 month (this time is the first) □ 2 months □ 3 months □ 4 months □ 5 months □ 6 months □ 7 months □ 8 months □ 9 months □ 10 months □ 11 months □ 12 months □ More than 12 months □ Client doesn’t know □ Client refused a. How long since client had permanent place to live (permanent address)? Place last lived 90 or more days; not shelter or time-limited housing
□ 0 (Prevention/Current Residence) □ Less than 1 month □ 1 – 3 months □ 3 – 6 months □ 6 – 12 months □ 1 – 2 years □ 3 – 5 years □ 6 – 8 years □ 9 years or more b. Location of the client’s last permanent address
State of Prior Residence: DK R NC
County of Prior Residence (MN only): DK R NC
City of Prior Residence (MN only): DK R NC
CoC of Service (Head of Household)
LTH Entry Form for Single Clients 7 of 9 hmismn.org Last updated 2/28/2018 MN-500 Hennepin MN-505 Central MN-501 Ramsey MN-506 Northwest MN-502 Southeast MN-508 West Central MN-503 SMAC MN-509 St. Louis MN-504 Northeast MN-511 Southwest
Client’s Residence Current Residence Status (enter # from list below) Start date City (in MN) County (in MN) Zip Code / /
1. Site-based supportive housing 6. Living with family 12. Place not meant for habitation 2. Scattered-site supportive housing 7. Living with friends 13. Jail, Prison or Juvenile facility 3. Transitional housing for homeless 8. Foster care/group home 14. Other 4. Emergency shelter 9. Hospital 15. Client does not know 5. Hotel/motel without emergency shelter 10. Psychiatric facility 16. Client refused 11. Substance abuse treatment center, including detox
Housing Cost (Required for clients in site-based and scattered-site supportive housing only.) Start Date (Current residence status start date) Amount client pays for rent
/ / $
Housing Subsidy Information (Required for clients in site-based and scattered-site supportive housing only.) Start Date (Current residence status start Primary Source of Subsidy date) (enter # from list below)
/ /
1. No subsidy 6. HOPWA 10. Section 8 2. Bridges 7. MHFA Rental 11. Shelter Plus Care 3. County Funded Assistance 12. Sons of Bridges 4. Housing Support 8. Property Subsidy 13. Other (specify): (GRH) 9. SHP Leasing 5. HOME
(If HIPAA) Include client in database research? Yes No LTH Entry Form for Single Clients 8 of 9 hmismn.org Last updated 2/28/2018 Housing Move-in Date: _____ / _____ /______(Month/Day/Year) (Permanent Housing Projects only)(Heads of Household (Including Singles and Youth Heads of Household)) (For clients with a Project Start Date in a permanent housing project, enter the date a client or household moves into a permanent housing unit)
Underlined terms have definitions provided at hmismn.org. Please print a copy to have available.
LTH Entry Form for Single Clients 9 of 9 hmismn.org Last updated 2/28/2018