<p> HMIS Client ID # OEO HYA Youth Supportive Housing (YSH) 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.</p><p>Demographics (in HMIS: use ClientPoint Search and Client Profile Tab)</p><p>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: OEO HYA YSH Entry Form for Single Clients 1 of 8 hmismn.org Last updated 3/3/2018 Program Entry (in HMIS: use Entry/Exit Tab)</p><p>1. Provider: 2. Type: 3. Project Start Date: _____ / _____ / _____ (Month/Day/Year)</p><p>MN: OEO HYA Youth Supportive Housing Assessment (In HMIS: Entry/Exit Tab)</p><p>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</p><p>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 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  No  Yes, National  Both Guard and Reserves in the National Guard or  Yes, Active Duty (regardless of Guard and Reserve Guard  DK  R  NC answers)  Yes, Reserves Reserves? (18+ only) If yes to questions a or b, answer questions c-h. If no, skip to next question series. c. If Guard or Reserve: Were you ever called to Active Duty Yes No  DK  R  NC as a member of the National Guard or as a Reservist? d. Did you enter Active Duty before 9/7/1980? Yes No  DK  R  NC</p><p> 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. Has the client been referred to the Homeless Veteran Yes No  DK  R  NC Registry? *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.</p><p>Are you or have you ever been in foster care? (Clients 24 or younger) OEO HYA YSH Entry Form for Single Clients 2 of 8 hmismn.org Last updated 3/3/2018  Yes  No  Client doesn’t know  Client refused  Data not collected Referral Source  Emergency Shelter  Family member  Self  Drop-in center  Social service provider  Other  Street outreach  School staff  Friend  Health provider 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 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</p><p>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. 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? Mental Health Problem (HUD)  Yes  No  DK  R  NC  Yes  No  DK  R  NC Physical (HUD)  Yes  No  DK  R  NC  Yes  No  DK  R  NC Developmental (HUD)  Yes  No  DK  R  NC  Yes  No  DK  R  NC Chronic Health Condition (HUD)  Yes  No  DK  R  NC  Yes  No  DK  R  NC Alcohol Abuse (HUD)  Yes  No  DK  R  NC  Yes  No  DK  R  NC OEO HYA YSH Entry Form for Single Clients 3 of 8 hmismn.org Last updated 3/3/2018 Traumatic Brain Traumatic Injury HIV/AIDS(HUD) AlcoholBoth Drug and Abuse (HUD) Abuse Drug (HUD) Lastupdated OEOHYA YSHEntry Form Single for Clients TANFCare Child Services (HUD) SpecialSupplemental Nutrition Program WIC for (HUD) (HUD) Supplemental Nutrition Program Assistance (Food Stamps) Non-Cash Benefitsb. is thedate project start date. “Receiving will benefit” “Yes” remain ifbenefiteven Do ends. notrecord an amount non-cash for benefits HMIS. in Tips: HMIS Non-cash fromsource benefitanya. Total monthly income: c. Monthly Income: b. (HUD)=HUD-approvedsource. Non-HUD-approvedincome sources can be entered usingthe “Add” button. Tips: HMIS Incomefrom source any a. Resources2. Section Other(Specify): ______Vision Impaired HearingImpaired RetirementIncome From Social Security(HUD) General Assistance (HUD) TANF(HUD) Worker’sCompensation (HUD) PrivateDisability Insurance (HUD) (HUD) VAService Connected DisabilityCompensation SSDI(HUD) SSI(HUD) UnemploymentInsurance (HUD) EarnedIncome (HUD) 3/3/2018 Enter non-cash benefits usingthe HUD Verification tool. Non-HUD-approved non-cash benefit sources be must entered usingthe “Add” button. Start Enter using income theHUD Verificationtool. Start is thedate project start date. “Receiving income will source” “yes,” evenremain ifincome ends. $______.00  Yes         </p><p>Yes Yes Yes Yes Yes Yes Yes No </p><p>Yes Yes                  </p><p>No No No No No No No Y Y Y Y Y Y Y Y Y Y Client know doesn’t           </p><p>No No N N N N N N N N N N N                 </p><p>DK DK DK DK DK DK DK Monthlyamount NC NC NC NC NC NC NC NC NC NC            Client doesn’t doesn’t knowClient $ $ $ $ $ $ $ $ $ $</p><p>R R R R R R R Yes Yes Yes Yes       </p><p>NC NC NC NC NC NC NC    No No No No  4 of Client refused    NC NC NC 8 TribalFunds StudentGrant/Scholarship MSA/MinnesotaSupplemental Aid Interest,Dividends, Annuities & ContributionsFrom Other People Other(specify) (HUD) ______AlimonyOtheror Spousal Support (HUD) Child Support (HUD) (HUD) Pensionor retirement income fromanother job (HUD) VANon-Service Connected Disability Pension Project Start Date        Othersource (HUD) ______OtherTANF-Funded (HUD) services TANFTransportation (HUD) services</p><p>Yes Yes Yes Yes Yes Yes Yes   Data notcollected Client refused Client       </p><p>No No No No No No No       </p><p>DK DK DK DK DK DK DK       </p><p>R R R R R R R R         Data not collectedData not</p><p>NC NC NC NC NC NC NC NC          </p><p>Y Y Y Y Y Y Y Y Y Y Y              hmismn.org</p><p>Yes Yes Yes N N N N N N N N N N           Monthlyamount NC NC NC NC NC NC NC NC NC NC    No No No No $ $ $ $ $ $ $ $ $ $    NC NC NC Section 3. Housing Situation</p><p>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</p><p>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</p><p>OEO HYA YSH Entry Form for Single Clients 5 of 8 hmismn.org Last updated 3/3/2018 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 </p><p>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 OEO HYA YSH Entry Form for Single Clients 6 of 8 hmismn.org Last updated 3/3/2018  One year or longer  Client doesn’t know  Data not collected  Client doesn’t know  Client refused  Client refused  Data not collected  Data not collected</p><p>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, in emergency shelter, or Safe Haven? □ Yes (Move to D) □ No (Done. Move to the next question “How long since client […]?” on the next page.)</p><p>D. Approximate date homelessness started _____/_____/______E. Number of times the client has been on the streets, in emergency shelter, or Safe Haven 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, in emergency shelter, or Safe Haven 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</p><p>How long since client had permanent place to live (permanent address)? Place last lived 90 or more days; not shelter or time-limited housing</p><p>□ 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</p><p>Location of the client’s last permanent address State of Prior Residence:  DK  R  NC </p><p>County of Prior Residence (MN only):  DK  R  NC</p><p>City of Prior Residence (MN only):  DK  R  NC</p><p>CoC of Service</p><p>OEO HYA YSH Entry Form for Single Clients 7 of 8 hmismn.org Last updated 3/3/2018  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</p><p>(If HIPAA) Include client in database research?  Yes  No </p><p>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)</p><p>Underlined terms have definitions provided at hmismn.org. Please print a copy to have available.</p><p>OEO HYA YSH Entry Form for Single Clients 8 of 8 hmismn.org Last updated 3/3/2018</p>