NewHampshireContinuaofCare

APR Housing Opportunities for People with AIDS (HOPWA)

Updates & Annual Assessment Formfor HMIS

This form is required byHUDfor eachadult client entering yourproject.

BOS TBRA / BOS Housing / BOS Info / BOS STRMU / BOS PHP
 MCOC TBRA /  MCOC Housing /  MCOC Info /  MCOC STRMU /  MCOC PHP

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

Update –Thesedataelementsrepresentinformationthatis either collectedat multiple pointsduringprojectenrollmentin orderto trackchangesovertime(e.g., Income)orisenteredto record projectactivitiesastheyoccur(e.g., ServicesProvided). TheInformationDate must reflectthedateonwhichtheinformationiscollectedand/orthe datefor whichthe informationis relevantforreportingpurposes and mustbeaccurate, regardless ofwhen itis actuallycollectedorentered intoHMIS.

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 updates yearly, 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.
/
  • 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 during Project stayand/or for the annual update.
  • Required to do annual assessment updates (see definition above).

Date Form Completed: __ __/ __ __/ ______
Case Manager’s Name: ______
Relationship to Head of Household (HoH)
 Self (HoH)  HoH’s child  HoH’s spouse/partner
 HoH’s other relation member  Other: non-relation member / Client’s ID #: ______

Updates to information No updates to information

Annual Update for APR

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

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

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.

Incomereceivedfromanysource? NoYesClient doesn’tknowClient refused
(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
Monthly Income Start 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
/ / / / / / / /
/ / / / / / / /

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-Cashbenefitreceivedfromanysource?NoYesClient doesn’tknowClient refused
(if yes, Information/Project Date) ____/____/______
MonthlyNon-CashBenefit Source:
SupplementalNutritionAssistProgram(SNAP/FoodStamps) $
SpecialSupplementalNutritionProgram(WIC)$
TANFChildCareservices$
TANFTransportationservices$
OtherTANF-fundedservices$ / OtherTANF-fundedservices $
Section8,publichousingorrentalassistance $
Temporaryrentalassistance$
OtherSource(specify)$
Receiving Benefit? NoYes
Non-CashMonthly Start 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
/ / / / / / / /
/ / / / / / / /

4. Health Insurance Updates (In ServicePoint use Entry/Exit Tab)-- Interim

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 if there is no change.
  • Updates are required for persons aging into adulthood.

Health Insurance Source:
(if yes,indicate all sources that apply)
Health Insurance Type / Covered? / If no, reason
MEDICAID / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
MEDICARE / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
State Children’s Health Insurance / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
Veteran’s Administration (VA) Medical Services / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
Employer-Provided Health Insurance / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
Health Insurance obtained through COBRA / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
Private pay health insurance / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client
Insurance Type: ______
State Health Insurance for Adults / NoYes / Applied, decision pending / Client doesn’t know
Applied, client not eligible / Client refused
Client did not apply /  Data Not Collected
Insurance type N/A for this client

5. Disability Updates (In ServicePoint use Entry/Exit Tab)

Does client have a disabling condition?NoYesClient doesn’tknowClient refused
(if yes, Information/Project Date) ____/____/______
  • Use this table to record new disabilities not recorded previously, or if an answer has changed since the last update.
  • If determination is “no” for any disability requiring documentation, change the determination to “no” in HMIS. This will prevent the disability from appearing on the APR.

Do you have a disability of long duration?NoYesClient doesn’tknowClient refused
(if yes, Information/ Project Entry Date) ____/____/______
Disability Type / Disability
Determination? / (If yes) Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? / (Ifyes)Documentation of the disability and severity on file? / (Ifyes)CurrentlyReceiving
ServicesorTreatment?
Alcohol Abuse / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
Both drug and alcohol abuse / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
ChronicHealthCondition / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
Developmental Disability / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
Drug Abuse / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
HIV/AIDS / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
MentalHealthProblem / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
Physical Disability / No Yes / NoYes CDK  C ref / NoYes CDK  C ref / NoYes CDK  C ref
Disability Notes(optional information about disability)
Will above condition be long term?NoYes

6. Domestic Violence

DomesticViolenceVictim/Survivor?
NoYes Client doesn’t knowClient refused / If yes, When Experience Occurred:
Withinthepast3monthsOne yearago or more
3- 6monthsago Client doesn’tknow
6- 12monthsago Client refused

7: Medical Assistance Updates

  • Use this table to record newmedical assistance not recorded previously, or if an answer has changed since the last update.

Receiving Public HIV/AIDS Medical Assistance? No Yes Client doesn’tknow Client refused  Data Not Collected
(if yes, Information/Project Exit Date) ____/____/______
(if no, choose a Reason):
Applied; pendingApplied; not eligibleClient did not apply Insurance type N/A for this client
Client doesn’t know Client refusedData Not Collected
Receiving AIDS Drug Assistance Program (ADAP)? NoYes Client doesn’tknowClient refused Data Not Collected
(if yes, Information/Project Exit Date) ____/____/______
(if no, choose a Reason):
Applied; pendingApplied; not eligibleClient did not apply Insurance type N/A for this client
Client doesn’t know Client refusedData Not Collected

8: Employment at Exit

  • Employment status is a required element for each adult per NH BHHS.

Employed? NoYesClient Doesn’t Know Client Refused  Data Not Collected
EmploymentTenure:
FullTime
PartTime

9. Services Provided

  • Use this table to record services that have been provided during project stay, or if an answer has changed since the last update.
  • Check all services that apply and the date that service started. If weekly service, must update each time service received.

Services Provided
Service Type
Adult day care and personal assistance
Case management
Child care
Criminal justice/legal services
Education
Employment and training services
Food/meals/nutritional services / Date
___/___/______
___/___/______
___/___/______
___/___/______
___/___/______
___/___/______
___/___/______ / Service Type
Health/medical care
Life skills training
Mental health care/counseling
Outreach and/or engagement
Substance abuse services/treatment
Transportation
Other HOPWA funded service ______/ Date
___/___/______
___/___/______
___/___/______
___/___/______
___/___/______
___/___/______
___/___/______

10: Financial Assistance Provided (in ServicePoint use Services Tab)

  • Use this table to record financial assistance that has been provided during project stay, or if an answer has changed since the last update.
  • Record for the Head of Household who receives Financial Assistance from HOPWA through Short-Term Rent, Mortgage, Utility Assistance (STRMU)

Financial Assistance Provided
Assistance Type
Rental assistance-STRMU
Utility payment-STRMU
Mortgage assistance-STRMU
Rental assistance – PHP project only
Security deposit – PHP project only
Utility deposit – PHP project only
Utility payment – PHP project only / Date
_____/_____/______
_____/_____/______
_____/_____/______
_____/_____/______
_____/_____/______
_____/_____/______
_____/_____/______/ Amount
$______
$______
$______
$______
$______
$______
$______

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

04/21/2015 HOPWA Updates & Annual Update Form Revision A2Page 1 of 7
New Hampshire Homeless Management Information System (NH-HMIS)