APR Housing Opportunities for People with AIDS (HOPWA)

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:

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)