NewHampshireContinuaofCare

HUD CoC APR TH PH ES

Annual Assessment Formfor HMIS

(Required byHUDfor eachclient at annual assessment)

Refer to the2014HUD HMIS Data Standardson the NH-HMIS website at for an explanation of the data elements in this form.

Annualassessment –Is a specialized subsetofthe‘update’ collectionpoint.Theannual assessmentmustberecordedno morethan 30days beforeoraftertheanniversaryof the client’sProject EntryDate,regardlessof thedateofthemostrecent ‘update’or ‘annual assessment’, if any[annually].Informationmustbeaccurateasof the InformationDate.

For HUD-funded programsand HUDreportingpurposes,theimplementationof ‘annual assessment’asadata collection stage byvendorsismandatory; thedatacollection stage mustnotbeinferred fromthe InformationDate, althoughthefieldmusthaveanInformationDaterecordedwith it. Inorder tobeconsidered reportabletoHUD as an annual assessment,datamustbestoredwith a DataCollectionStageof ‘annual assessment.’

Theremust beonlyone recordfor eachdataelementannually withaData CollectionStage recorded as ‘annual assessment’associated with any given clientand projectentryIDwithin the 60-dayperiodsurroundingtheanniversaryoftheclient’sProject EntryDate.Regardless of whetherthe responseshavechanged sinceprojectentryorthe previous annual assessment,anewrecordmustbecreatedforeach subsequent annual assessment such that it ispossible toviewa history,bydate,ofthevaluesfor eachdataelement.

Data Collection and HMIS Instruction Tips:
  • Complete the annual updates, before your program’s APR is due.
  • Only record if the answer has changed since last update.
  • Always set the Entry Data Type to “HUD”.
  • In ServicePoint, confirm backdate matches project entry date.
  • When a child turns 18 during a project stay, the child’s intake assessment must be updated to includeresponses only required for adults, e.g. disabling condition.
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  • Do NOT enter “Client doesn’t know” or “Client refused” unless the client tells you they do not know or they refuse to answer.
  • Use this form to make updates to client’s information for their annual update.
  • Annual assessment updates (see definition above) are required.

Date Form Completed: __ __/ __ __/ ______
Case Manager’s Name: ______/ Client’s ID #: ______

 Updates to information  No updates to information

Section 1: Client Profile (in ServicePoint use Entry/Exit Tab)

Client’s First, Middle,Last Name,Suffix:______
Client’s Location: (chooseone HUD-assigned CoC Code) / NH-500 (Balance of State/Concord)
NH-501 (Manchester)
NH-502 (Nashua)

Section 2: Income Updates (in ServicePoint use Entry/Exit Tab)

HMIS Instructions:
  • *Info/Project Date: If income source and amount was present at program entry, use program entry date.
  • If NEW income source or amount, use actual start date or other date before the end of the report period.
  • If income amount for a source has changed, in SP, record end date for the old amount one day before the start date of the new amount. Add new income record for that source.
  • “Receiving income source” is always “yes,” even if the amount/source ends.
  • Ask client whether they receive income from EACH source listed rather than asking them to state the sources of income they receive.

Incomefromanysource? NoYesClient doesn’tknowClient refused Data not collected
(if yes, Information/Project Date*) ____/____/______
MonthlyIncome(cash) Source:
EarnedIncome (i.e., employment income)$
UnemploymentInsurance$
Supplemental Security Income (SSI)$
Social Security Disability Income (SSDI)$
VA Service-ConnectedDisabilityCompensation$
VA Non-Service-ConnectedDisabilityPension$
Privatedisabilityinsurance$
Worker’scompensation$ / TANF$
RetirementIncomefromSocialSecurity$
Pensionor retirement income from former job$
Childsupport$
Alimonyorotherspousalsupport$
Othersource (specify)$
Receiving Income Source NoYes Data not collected
Monthly Income Start Date: ___/___/______Monthly Income End Date: ___/___/______
Monthly Income Total $______

2a. Cash income sources recorded at entry that have since ENDED or changed: List below with end dates:

Income Source 1 (enter source from list above) / End date / Income Source 2 (enter source from list above) / End date / Income Source 3 (enter #source from list above) / End date
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /

Section 3: Non-Cash Benefits Updates (in ServicePoint use Entry/Exit Tab)

  • Ask client whether they receive benefits from EACH source listed rather than asking them to state the sources of income they receive.
  • “Receiving income source” is always “yes,” even if the amount/source ends.

Non-Cashbenefitfromanysource?NoYesClient doesn’tknowClient refused Data not collected
(if yes, Information/Project Date) ____/____/______
MonthlyNon-CashBenefit Source:
SupplementalNutritionAssistProgram(SNAP/FoodStamps) $
SpecialSupplementalNutritionProgram(WIC)$
TANFChildCareservices$
TANFTransportationservices$
OtherTANF-fundedservices$ / Section8,publichousingorrentalassistance $
Temporaryrentalassistance$
OtherSource(specify)$
Receiving Benefit? NoYes Data not collected
Non-CashMonthly Start Date: ___/___/______Non-CashMonthly End Date: ___/___/______
Non-CashMonthly Total $______

3a. Non-cash benefits recorded at entry or at updates that have since ENDEDor changed: List below with end dates:

Income Source 1 (enter source from list above) / End date / Income Source 2 (enter source from list above) / End date / Income Source 3 (enter #source from list above) / End date
/ / / / / / / /
/ / / / / / / /
/ / / / / / / /

Section 4:Health Insurance Updates (In ServicePoint use Entry/Exit Tab)

Data collection and HMIS instructions:
  • Use this table to record new insurance not recorded previously, or if an answer has changed since the last update.
  • Health insurance must be recorded in HMIS as an annual assessment, even is there is no change.
  • Updates are required for persons aging into adulthood.

Covered by health insurance?NoYesClient doesn’tknowClient refused Data not collected
(if yes, Information/ Project Entry Date) ______/______/______
Health Insurance Source:
(if yes, indicate all sources that apply)
(if no, enter one of the following reasons on the line provided):
Applied; pendingApplied; not eligible Client did not apply Insurance type N/A for this client Client doesn’t know Client refused
Reason Start Date End Date
NoYesMEDICAID ______/ / / /
NoYesMEDICARE______/ / / /
NoYesState Children’s Health Insurance Program ______/ / / /
NoYesVeteran’s Administration (VA) Medical Services______/ / / /
NoYesEmployer-Provided Health Insurance______/ / / /
NoYesHealth Insurance obtained through COBRA______/ / / /
NoYesPrivate pay health insurance______/ / / /
NoYesState Health Insurance for Adults______/ / / /

This form can be found on the NH-HMIS website at

1/2015 HUD CoC APR TH PH ESAnnual Assessment Form Page 1 of 4
New Hampshire Homeless Management Information System (NH-HMIS)