HUD CoC and ESG Entry Intake Form

HUD CoC and ESG Entry Intake Form
DATE
Fill out a separate form for each household member at the time of program entry. Clip all households member forms together.
Name
First
M
Social Security Number
Last
Name Data Quality
Full name reported
Partial or street name reported
Client doesn’t know
Client refused
Data not collected
U.S. Military Veteran?
Yes (HUD)
No (HUD)
Client doesn’t know
Client refused
Data not collected
SSN Data Quality
Date of Birth*
Primary Race*
Secondary Race - If Applicable
American Indian or Alaska Native (HUD)
Date of Birth type*
Full DOB reported (HUD)
Approximate/partial DOB reported
Client doesn’t know
Client refused
Data not collected
American Indian or Alaska Native (HUD)
Asian (HUD)
Black or African American (HUD)
Native Hawaiian or Other Pacific Islander
White (HUD)
Client doesn’t know
Client refused
Data not collected
Asian (HUD)
Black or African American (HUD)
Native Hawaiian or Other Pacific Islander (HUD)
White (HUD)
Client doesn’t know
Client refused
Data not collected
Ethnicity*
Client Location*
Non-Hispanic/Non-Latino
Hispanic/Latino
Client doesn’t know
Client refused
Data not collected
Gender*
Female
Male
Transgender male to female
Transgender female to male
Other: Specify
Client doesn’t know
Client refused
Data not collected
TX-503 Austin and Travis County
TX-607 Surrounding counties
If Yes for DV Victim/Survivor,
when Experience Occurred:
Domestic Violence Victim/Survivor?
Yes
No
Client doesn’t know
Within the past three months
Six months to one year ago (excluding one
Three to six months ago
(excluding 6months exactly)
Client refused
Data not collected
Health Insurance
Full SSN reported
Approximate or partial SSN reported
Client doesn’t know
Client refused
Data not collected
Client Enrolled in MAP ?
Yes
No
Client doesn’t know
Client refused
Data not collected
One year ago or more
Client doesn’t know
Client refused
Data not collected
HUD Verifications
Covered by any of these Health Insurance types: Yes
No
MEDICAID
MEDICARE
State Children's Health Insurance Program
Veterans Administration (VA) Medical Services
Employer– Provided Health Insurance
Health Insurance obtained through COBRA
State Health insurance For Adults
Private Pay Health Insurance
Monthly Income/Benefits and sources*
Receiving any of the following income sources:
Earned income (i.e., employment income)
Alimony or Other Spousal Support (HUD)
Child Support (HUD)
General Assistance (HUD)
Other (HUD)
Pension or retirement income from another job (HUD)
Private Disability Insurance (HUD)
Retirement Income From Social Security (HUD)
SSDI (HUD)
SSI (HUD)
TANF (HUD)
Unemployment Insurance (HUD)
VA Service Connected Disability Compensation (HUD)
VA Non-Service Connected Disability Pension (HUD)
Worker's Compensation (HUD)
!
Non-Cash Benefits*
HUD Verifications
Receiving any of the following Non-Cash benefit sources:
Yes No
Monthly
Amount
!
Start
Date
Supplemental Nutrition Assistance Program (Food Stamps) (HUD)
Special Supplemental Nutrition Program for WIC (HUD)
TANF Child Care Services (HUD)
TANF Transportation Services (HUD)
Other TANF-Funded Services (HUD)
Section 8, Public Housing, or other ongoing rental assistance (HUD)
Other Source (HUD)
Temporary rental assistance (HUD)
HUD Verifications
Yes No
Monthly
amount
start
date
!
Disabilities*
Does client have any disabilities:
HUD Verifications
Yes No
!
Expected to be of long duration?
Alcohol Abuse (HUD)
Drug Abuse (HUD)
Both Alcohol and Drug Abuse (HUD)
Chronic Health Condition (HUD)
Developmental (HUD)
HIV/AIDS (HUD)
Mental Health Problem (HUD)
Physical (HUD)
Verification of information captured above:
Covered by Health Insurance?
Income from Any Source?
Non-cash Benefit from any source?
Does Client Have Disabling Condition?
Yes
No
HUD CoC and ESG Entry Intake Form
Chronic homeless status is determined by a client’s history of homelessness, disability status, and the length of time spent on
the street, in an emergency shelter or a Safe Haven. The following questions help to identify Chronically homeless:
Residence Prior to Project Entry
Emergency shelter, including hotel or motel paid for with
emergency shelter voucher
Foster care home or foster care group home
Hospital or other residential non-psychiatric medical facility
Hotel or motel paid for without emergency shelter voucher
Jail, prison or juvenile detention facility
Long-term care facility or nursing home
Owned by client, no ongoing housing subsidy
Owned by client, with ongoing housing subsidy
Permanent housing for formerly homeless persons
(such as: CoC project; HUD legacy programs; or HOPWA PH)
Place not meant for habitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere outside)
Psychiatric hospital or other psychiatric facility
Rental by client, with VASH subsidy
Rental by client, with GPD TIP subsidy
Rental by client, with other ongoing housing subsidy
Residential project or halfway house with no homeless criteria
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
Substance abuse treatment facility or detox center
Transitional housing for homeless persons (including homeless
youth)
Other
Client doesn’t know
Client refused
Data not collected
Length of Stay in Previous Place
One day or less
Two days to one week
More than one week, but less than one month
One to three months
More than three months, but less than one year
One year or longer
Is Client Chronically homeless?
Yes (HUD)
No HUD)
Housing Status
Category 1 – Homeless (HUD)
Category 2 – At imminent risk of losing housing (HUD)
Category 3 – Homeless only under other federal statutes
Category 4 – Fleeing domestic violence
At-risk of homelessness
Stably housed
Client doesn’t know
Client refused
Data not collected
Names of individuals in household entering
the program with you (or ServicePoint #):
Relationship to Head of Household
Self (head of household)
Head of household’s child
Head of household’s spouse or partner
Head of household’s other relation member
(other relation to head of household)
Continuously Homeless for at Least One Year?
Yes (HUD)
No HUD)
Client doesn’t know
Client refused
Data not collected
Number of Times the Client has been Homeless in the Past Three Years
0
1
2
3
4 or more
Other
Client doesn’t know
Client refused
Data not collected
(If 4 or more) Total Number of Months Homeless in the Past Three Years:
0
1
2
3
4
5
6
7
8
9
10
11
12
More than 12
Other
Client doesn’t know
Client refused
Data not collected
Total Number of Months Continuously Homeless Immediately Prior
to Project Entry
(partial months i.e. 1 day - 30 days =
1 month)
Length of Time Homeless - Status Documented?
Yes (HUD)
No HUD)
Remember, you are taking a persons story and converting it into HUD speak data elements plus ServicePoint database functionality, take your time with a client and record the data accurately.