Middle Name:mrinstruction#
Last Name:
mrinstruction#
Name Data Qualitymrinstruction
%NameQual,Full_name_reported,29% / Full name reported / %NameQual,Partial_street_name_or_code_name_reported,30% / Partial, street name, or code name reported / %NameQual,Client_doesn_t_know,31% / Client doesn't know / %NameQual,Client_refused,32% / Client refused
Social Security Numbermrinstruction#
Social Security Number Qualitymrinstruction
%SSNQual,Full_SSN_reported,33% / Full SSN reported / %SSNQual,Approximate_or_partial_SSN_reported,34% / Approximate or partial SSN reported / %SSNQual,Client_doesn_t_know,31% / Client doesn't know / %SSNQual,Client_refused,32% / Client refused
Date of Birth(yyyy mm dd)
Date of Birth Typemrinstruction
%DOBQual,Full_DOB_reported,35% / Full DOB reported / %DOBQual,Approximate_or_partial_DOB_reported,36% / Approximate or partial DOB reported / %DOBQual,Client_doesn_t_know,31% / Client doesn't know / %DOBQual,Client_refused,32% / Client refused
Racemrinstruction
%Race,American_Indian_or_Alaska_Native,37% / American Indian or Alaska Native / %Race,Asian,38% / Asian / %Race,Black_or_African_American,39% / Black or African American / %Race,Native_Hawaiian_or_Other_Pacific_Islander,40% / Native Hawaiian or Other Pacific Islander
%Race,White,41% / White / %Race,Client_doesn_t_know,31% / Client doesn't know / %Race,Client_refused,32% / Client refused
Ethnicitymrinstruction
%Eth,Non_Hispanic_Non_Latino,42% / Non-Hispanic/Non-Latino / %Eth,Hispanic_Latino,43% / Hispanic/Latino / %Eth,Client_doesn_t_know,31% / Client doesn't know / %Eth,Client_refused,32% / Client refused
Gendermrinstruction
%Gender,Female,44% / Female / %Gender,Male,45% / Male / %Gender,Transgender_male_to_female,46% / Transgender male to female / %Gender,Transgender_female_to_male,47% / Transgender female to male
%Gender,Other,5% / Other / %Gender,Client_doesn_t_know,31% / Client doesn't know / %Gender,Client_refused,32% / Client refused
If other, please specify: mrinstruction#
Veteran Statusmrinstruction
%Vet,No,48% / No / %Vet,Yes,49% / Yes / %Vet,Client_doesn_t_know,31% / Client doesn't know / %Vet,Client_refused,32% / Client refused
HUD Assessment Information
Project Entry Date(yyyy mm dd)Relationship to Head of Household
%HoH,Self_head_of_household_,90% / Self (head of household) / %HoH,Head_of_household_s_child,91% / Head of household's child / %HoH,Head_of_household_s_spouse_or_partner,92% / Head of household's spouse or partner
%HoH,Head_of_household_s_other_relation_member_other_relation_to_head_of_household_,93% / Head of household's other relation member (other relation to head of household) / %HoH,Other_non_relation_member,94% / Other: non-relation member
Residence Prior to Entrymrinstruction
%ResPrior,Emergency_shelter_including_hotel_or_motel_paid_for_with_emergency_shelter_voucher,50% / Emergency shelter, including hotel or motel paid for with emergency shelter voucherottext
%ResPrior,Foster_care_home_or_foster_care_group_home,51% / Foster care home or foster care group homeottext
%ResPrior,Hospital_or_other_residential_non_psychiatric_medical_facility,52% / Hospital or other residential non-psychiatric medical facilityottext
%ResPrior,Hotel_or_motel_paid_for_without_emergency_shelter_voucher,53% / Hotel or motel paid for without emergency shelter voucherottext
%ResPrior,Jail_prison_or_juvenile_detention_facility,54% / Jail, prison or juvenile detention facilityottext
%ResPrior,Long_term_care_facility_or_nursing_home,55% / Long-term care facility or nursing homeottext
%ResPrior,Owned_by_client_no_ongoing_housing_subsidy,56% / Owned by client, no ongoing housing subsidyottext
%ResPrior,Owned_by_client_with_ongoing_housing_subsidy,57% / Owned by client, with ongoing housing subsidyottext
%ResPrior,Permanent_housing_for_formerly_homeless_persons_such_as_CoC_project_HUD_legacy_program_or_HOPWA_PH_,58% / Permanent housing for formerly homeless persons (such as CoC project, HUD legacy program, HOPWA PH)ottext
%ResPrior,Place_not_meant_for_habitation_e_g_a_vehicle_an_abandoned_building_bus_train_subway_station_airport_or_anywhere_outside_,59% / Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) ottext
%ResPrior,Psychiatic_hospital_or_other_psychiatric_facility,60% / Psychiatric hospital or other psychiatric facilityottext
%ResPrior,Rental_by_client_no_ongoing_subsidy,61% / Rental by client, no ongoing subsidyottext
%ResPrior,Rental_by_client_with_VASH_subsidy,62% / Rental by client, with VASH subsidyottext
%ResPrior,Rental_by_client_with_GPD_TIP_subsidy,63% / Rental by client, with GPD TIP subsidyottext
%ResPrior,Rental_by_client_with_other_ongoing_housing_subsidy,64% / Rental by client, with other ongoing housing subsidyottext
%ResPrior,Residential_project_or_halfway_house_with_no_homeless_criteria,65% / Residential project or halfway house with no homeless criteriaottext
%ResPrior,Safe_Haven,66% / Safe Havenottext
%ResPrior,Staying_or_living_in_a_family_member_s_room_apartment_or_house,67% / Staying or living in a family member's room, apartment or houseottext
%ResPrior,Staying_or_living_in_a_friend_s_room_apartment_or_house,68% / Staying or living in a friend's room, apartment or houseottext
%ResPrior,Substance_abuse_treatment_facility_or_detox_center,69% / Substance abuse treatment facility or detox centerottext
%ResPrior,Transitional_housing_for_homeless_persons_including_homeless_youth_,70% / Transitional housing for homeless persons (including homeless youth)ottext
%ResPrior,Other,5% / Otherottext
%ResPrior,Client_doesn_t_know,31% / Client doesn't knowottext
%ResPrior,Client_refused,32% / Client refusedottext
If other, please specify:mrinstruction#
mrinstruction
Length of Stay in Previous Residence:
%LOS,One_day_or_less,71% / One day or less / %LOS,More_than_three_months_but_less_than_one_year,76% / More than three months, but less than one year
%LOS,Two_days_to_one_week,74% / Two days to one week / %LOS,One_year_or_longer,73% / One year or longer
%LOS,More_than_one_week_but_less_than_one_month,75% / More than one week, but less than one month / %LOS,Client_doesn_t_know,31% / Client doesn't know
%LOS,One_to_three_months,72% / One to three months / %LOS,Client_refused,32% / Client refused
CoC Code Information Date(date of first contact in CoC) / CoC Code
/ / / NY - 600
Continuously Homeless for at Least One Year?mrinstruction
%LeastYear,No,48% / No / %LeastYear,Yes,49% / Yes / %LeastYear,Client_doesn_t_know,31% / Client doesn't know / %LeastYear,Client_refused,32% / Client refused
Number of Times the Client has been Homeless in the Past Three Years:mrinstruction
%NumberTime3,_0_not_homeless_Prevention_only_,95% / 0 (not homeless - Prevention only) / %NumberTime3,_1_homeless_only_this_time_,96% / 1 (homeless only this time) / %NumberTime3,_2,97% / 2 / %NumberTime3,_3,98% / 3
%NumberTime3,_4_or_more,99% / 4 or more / %NumberTime3,Client_doesn_t_know,31% / Client doesn't know / %NumberTime3,Client_refused,32% / Client refused
(If 4 or more) Total Number of Months Homeless in the Past Three Years(number value 0-12 or select option below):mrinstruction
%FourMOre,_10,102% / 12 or more / %FourMOre,_11,103% / Client doesn't know / %FourMOre,_12,104% / Client refused
Total Number of Months Continuously Homeless:mrinstruction# - #
Homeless Status Documented?mrinstruction
%Doc,No,48% / No / %Doc,Yes,49% / Yes / gototextQ#
Sexual Orientationmrinstruction
%SexOrien,Heterosexual,144% / Heterosexual / %SexOrien,Gay,145% / Gay / %SexOrien,Lesbian,146% / Lesbian / %SexOrien,Bisexual,147% / Bisexual
%SexOrien,Questioning_Unsure,148% / Questioning/Unsure / %SexOrien,Client_Doesn_t_Know,31% / Client doesn't know / %SexOrien,Clie,149% / Client refused
Pregnancy Statusmrinstruction
%PregStatus,No,48% / No / %PregStatus,Yes,49% / Yes / %PregStatus,Client_doesn_t_know,31% / Client doesn't know / %PregStatus,Client_refused,32% / Client refused
(If yes) Due Date(yyyy mm dd)
Received something in exchange for sex in the past three months?mrinstruction
%CommExp,No,48% / No / %CommExp,Yes,49% / Yes / %CommExp,Client_doesn_t_know,31% / Client doesn't know / %CommExp,Client_refused,32% / Client refused
(If yes) Number of times:mrinstruction
%NumbEx,_1_3,150% / 1-3 / %NumbEx,_4_7,151% / 4-7 / %NumbEx,_8_30,152% / 8-30
%NumbEx,More_than_30,153% / More than 30 / %NumbEx,Client_doesn_t_know,31% / Client doesn't know / %NumbEx,Client_refused,32% / Client refused
(If yes) Did someone ask/make you have sex?mrinstruction
%Force,No,48% / No / %Force,Yes,49% / Yes / %Force,Client_doesn_t_know,31% / Client doesn't know / %Force,Client_refused,32% / Client refused
Project Exit Date(yyyy mm dd)
Destinationmrinstruction
%Dest,Deceased,77% / Deceasedottext
%Dest,Emergency_shelter_including_hotel_or_motel_paid_for_with_emergency_shelter_voucher,50% / Emergency shelter, including hotel or motel paid for with emergency shelter voucherottext
%Dest,Foster_care_home_or_foster_care_group_home,51% / Foster care home or foster care group homeottext
%Dest,Hospital_or_other_residential_non_psychiatric_medical_facility,52% / Hospital or other residential non-psychiatric medical facilityottext
%Dest,Hotel_or_motel_paid_for_without_emergency_shelter_voucher,53% / Hotel or motel paid for without emergency shelter voucherottext
%Dest,Jail_prison_or_juvenile_detention_facility,54% / Jail, prison or juvenile detention facilityottext
%Dest,Long_term_care_facility_or_nursing_home,55% / Long-term care facility or nursing homeottext
%Dest,Moved_from_one_HOPWA_funded_project_to_HOPWA_PH,78% / Moved from one HOPWA funded project to HOPWA PHottext
%Dest,Moved_from_one_HOPWA_funded_project_to_HOPWA_TH,79% / Moved from one HOPWA funded project to HOPWA THottext
%Dest,Owned_by_client_no_ongoing_housing_subsidy,56% / Owned by client, no ongoing housing subsidyottext
%Dest,Owned_by_client_with_ongoing_housing_subsidy,57% / Owned by client, with ongoing housing subsidyottext
%Dest,Permanent_housing_for_formerly_homeless_persons_such_as_CoC_project_or_HUD_legacy_programs_or_HOPWA_PH_,80% / Permanent housing for formerly homeless persons (such as: CoC project, HUD legacy programs, HOPWA PH)ottext
%Dest,Place_not_meant_for_habitation_e_g_a_vehicle_an_abandoned_building_bus_train_subway_station_airport_or_anywhere_outside_,59% / Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) ottext
%Dest,Psychiatric_hospital_or_other_psychiatric_facility,81% / Psychiatric hospital or other psychiatric facilityottext
%Dest,Rental_by_client_no_ongoing_housing_subsidy,82% / Rental by client, no ongoing housing subsidyottext
%Dest,Rental_by_client_with_VASH_housing_subsidy,83% / Rental by client, with VASH housing subsidyottext
%Dest,Rental_by_client_with_GPD_TIP_housing_subsidy,84% / Rental by client, with GPD TIP housing subsidyottext
%Dest,Rental_by_client_with_other_ongoing_housing_subsidy,64% / Rental by client, with other ongoing housing subsidyottext
%Dest,Residential_project_or_halfway_house_with_no_homeless_criteria,65% / Residential project or halfway house with no homeless criteriaottext
%Dest,Safe_Haven,66% / Safe Havenottext
%Dest,Staying_or_living_with_family_permanent_tenure,85% / Staying or living with family, permanent tenureottext
%Dest,Staying_or_living_with_family_temporary_tenure_e_g_room_apartment_or_house_,86% / Staying or living with family, temporary tenure (e.g., room, apartment or house)ottext
%Dest,Staying_or_living_with_friends_permanent_tenure,87% / Staying or living with friends, permanent tenureottext
%Dest,Staying_or_living_with_friends_temporary_tenure_e_g_room_apartment_or_house_,88% / Staying or living with friends, temporary tenure (e.g., room, apartment or house)ottext
%Dest,Substance_abuse_treatment_facility_or_detox_center,69% / Substance abuse treatment facility or detox centerottext
%Dest,Transitional_housing_for_homeless_persons_including_homeless_youth_,70% / Transitional housing for homeless persons (including homeless youth)ottext
%Dest,Other,5% / Otherottext
%Dest,No_exit_interview_completed,89% / No exit interview completedottext
%Dest,Client_doesn_t_know,31% / Client doesn't knowottext
%Dest,Client_refused,32% / Client refusedottext
If other, please specify:mrinstruction#
Insurance Information – HUD Assessment
Covered by Health Insurance?%HealthInsur,No,48% / No / %HealthInsur,Yes,49% / Yes / %HealthInsur,Client_doesn_t_know,31% / Client doesn't know / %HealthInsur,Client_refused,32% / Client refused
Information Date (Date information provided):
If yes, please indicate all sources that applymrinstruction
Yes / No
Medicaid / %HealthChoice[{Medicaid}].SingleResponseQuestion,Yes,49% / %HealthChoice[{Medicaid}].SingleResponseQuestion,No,48%
Medicare / %HealthChoice[{Medicare}].SingleResponseQuestion,Yes,49% / %HealthChoice[{Medicare}].SingleResponseQuestion,No,48%
State Children's Health Insurance Program / %HealthChoice[{State_Children_s_Health_Insurance_Program}].SingleResponseQuestion,Yes,49% / %HealthChoice[{State_Children_s_Health_Insurance_Program}].SingleResponseQuestion,No,48%
Veteran's Administration Medical Services / %HealthChoice[{Veteran_s_Administration_Medical_Services}].SingleResponseQuestion,Yes,49% / %HealthChoice[{Veteran_s_Administration_Medical_Services}].SingleResponseQuestion,No,48%
Employer-Provided Health Insurance / %HealthChoice[{Employer_Provided_Health_Insurance}].SingleResponseQuestion,Yes,49% / %HealthChoice[{Employer_Provided_Health_Insurance}].SingleResponseQuestion,No,48%
Health Insurance Obtained Through COBRA / %HealthChoice[{Health_Insurance_Obtained_Through_COBRA}].SingleResponseQuestion,Yes,49% / %HealthChoice[{Health_Insurance_Obtained_Through_COBRA}].SingleResponseQuestion,No,48%
Private Pay Health Insurance / %HealthChoice[{Private_Pay_Health_Insurance}].SingleResponseQuestion,Yes,49% / %HealthChoice[{Private_Pay_Health_Insurance}].SingleResponseQuestion,No,48%
State Health Insurance for Adults / %HealthChoice[{State_Health_Insurance_for_Adults}].SingleResponseQuestion,Yes,49% / %HealthChoice[{State_Health_Insurance_for_Adults}].SingleResponseQuestion,No,48%
Disability Information – HUD Assessment
1. Physical Disability?mrinstruction%PhysDis,No,48% / No / %PhysDis,Yes,49% / Yes / %PhysDis,Client_doesn_t_know,31% / Client doesn't know / %PhysDis,Client_refused,32% / Client refused
Information Date(Date information provided):
1a. (If yes), Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?mrinstruction
%PDLong,No,48% / No / %PDLong,Yes,49% / Yes / %PDLong,Client_doesn_t_know,31% / Client doesn't know / %PDLong,Client_refused,32% / Client refused
1b. (If yes), Documentation of the disability and severity on file?mrinstruction
%PDDoc,No,48% / No / gototextQ# / %PDDoc,Yes,49% / Yes / gototextQ#
1c. (If yes) Currently receiving services/treatment for this disability?mrinstruction
%PDTreat,No,48% / No / %PDTreat,Yes,49% / Yes / %PDTreat,Client_doesn_t_know,31% / Client doesn't know / %PDTreat,Client_refused,32% / Client refused
2. Developmental Disability?mrinstruction
%DevDis,No,48% / No / %DevDis,Yes,49% / Yes / %DevDis,Client_doesn_t_know,31% / Client doesn't know / %DevDis,Client_refused,32% / Client refused
Information Date(Date information provided):mrQuestionText
2a. (If yes), Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?mrinstruction
%DevLong,No,48% / No / %DevLong,Yes,49% / Yes / %DevLong,Client_doesn_t_know,31% / Client doesn't know / %DevLong,Client_refused,32% / Client refused
2b. (If yes), Documentation of the disability and severity on file?mrinstruction
%DevDoc,No,48% / No / gototextQ# / %DevDoc,Yes,49% / Yes / gototextQ#
2c. (If yes) Currently receiving services/treatment for this disability?mrinstruction
%DevTreat,No,48% / No / %DevTreat,Yes,49% / Yes / %DevTreat,Client_doesn_t_know,31% / Client doesn't know / %DevTreat,Client_refused,32% / Client refused
3. Chronic Disability?mrinstruction
%ChronDis,No,48% / No / %ChronDis,Yes,49% / Yes / %ChronDis,Client_doesn_t_know,31% / Client doesn't know / %ChronDis,Client_refused,32% / Client refused
Information Date(Date information provided):mrQuestionText
3a. (If yes), Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?mrinstruction
%ChronLong,No,48% / No / %ChronLong,Yes,49% / Yes / %ChronLong,Client_doesn_t_know,31% / Client doesn't know / %ChronLong,Client_refused,32% / Client refused
3b. (If yes), Documentation of the disability and severity on file?mrinstruction
%DevDoc,No,48% / No / gototextQ# / %DevDoc,Yes,49% / Yes / gototextQ#
3c. (If yes) Currently receiving services/treatment for this disability?mrinstruction
%ChronTreat,No,48% / No / %ChronTreat,Yes,49% / Yes / %ChronTreat,Client_doesn_t_know,31% / Client doesn't know / %ChronTreat,Client_refused,32% / Client refused
4. Mental Health Problem?mrinstruction
%MentalDis,No,48% / No / %MentalDis,Yes,49% / Yes / %MentalDis,Client_doesn_t_know,31% / Client doesn't know / %MentalDis,Client_refused,32% / Client refused
Information Date(Date information provided):mrQuestionText
4a. (If yes), Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?mrinstruction
%MentalLong,No,48% / No / %MentalLong,Yes,49% / Yes / %MentalLong,Client_doesn_t_know,31% / Client doesn't know / %MentalLong,Client_refused,32% / Client refused
4b. (If yes), Documentation of the disability and severity on file?mrinstruction
%MentalDoc,No,48% / No / gototextQ# / %MentalDoc,Yes,49% / Yes / gototextQ#
4c. (If yes) Currently receiving services/treatment for this disability?mrinstruction
%MentalTreat,No,48% / No / %MentalTreat,Yes,49% / Yes / %MentalTreat,Client_doesn_t_know,31% / Client doesn't know / %MentalTreat,Client_refused,32% / Client refused
5. Substance Abuse Problem?mrinstruction
%SubProb,No,48% / No / %SubProb,Yes,49% / Alcohol abuse / %SubProb,Client_doesn_t_know,31% / Drug abuse
%SubProb,Client_refused,32% / Both alcohol and drug abuse / %SubProb,Client_doesn_t_know1,120% / Client doesn't know / %SubProb,Client_refused1,121% / Client refused
Information Date(Date information provided):mrQuestionText
5a. (If yes), Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?mrinstruction
%AlcLong,No,48% / No / %AlcLong,Yes,49% / Yes / %AlcLong,Client_doesn_t_know,31% / Client doesn't know / %AlcLong,Client_refused,32% / Client refused
5b. (If yes), Documentation of the disability and severity on file?mrinstruction
%SubDoc,No,48% / No / gototextQ# / %SubDoc,Yes,49% / Yes / gototextQ#
5c. (If yes) Currently receiving services/treatment for this disability?mrinstruction
%AlcTreat,No,48% / No / %AlcTreat,Yes,49% / Yes / %AlcTreat,Client_doesn_t_know,31% / Client doesn't know / %AlcTreat,Client_refused,32% / Client refused
Information about Contact – Services and Referrals Screen
Date of Contact(yyyy mm dd)Location of Contactmrinstruction
%Location,Place_not_meant_for_habitation,122% / Place not meant for habitation / %Location,Service_setting_non_residential,123% / Service setting, non-residential / %Location,Service_setting_residential,124% / Service setting, residential
**Date of Engagement(yyyy mm dd) (**if client does not engage, leave blank)
Services Providedmrinstruction
%Services,Health_and_Hygiene_Products_Distributed,125% / Health and Hygiene Products Distributed / %Services,Food_and_Drink_Items,126% / Food and Drink Items / %Services,Services_Information_Brochures,127% / Services Information/Brochures
Type of Referralmrinstruction
%TypeRef,Child_Care_Non_TANF,128% / Child Care Non-TANFottext
%TypeRef,Supplemental_Nutrition_Assistance_Program_Food_Stamps_,129% / Supplemental Nutrition Assistance Program (Food Stamps)ottext
%TypeRef,Education_McKinney_Vento_Liaison_Assistane_to_Remain_in_School,132% / Education - McKinney/Vento Liaison Assistance to Remain in Schoolottext
%TypeRef,HUD_Section_8_or_Other_Permanent_Housing_Assistance,133% / HUD Section 8 or Other Permanent Housing Assistanceottext
%TypeRef,Individual_Development_Account,134% / Individual Development Accountottext
%TypeRef,Medicaid,112% / Medicaidottext
%TypeRef,Mentoring_Program_Other_than_RHY_Agency,135% / Mentoring Program Other than RHY Agencyottext
%TypeRef,National_Service_Americorp_VISTA_Learn_and_Serve_,136% / National Service (AmeriCorps, VISTA, Learn and Serve)ottext
%TypeRef,Non_Residential_Substance_Abuse_or_Mental_Health_Program,137% / Non-Residential Substance Abuse or Mental Health Programottext
%TypeRef,Other_Public_Federal_State_or_Local_Program,138% / Other Public - Federal, State or Local Programottext
%TypeRef,Private_Non_profit_Charity_or_Foundation_Support,139% / Private Non-profit Charity or Foundation Supportottext
%TypeRef,SCHIP,130% / SCHIPottext
%TypeRef,SSI_SSDI_or_other_Disability_Insurance,131% / SSI, SSDI, or other Disability Insuranceottext
%TypeRef,TANF_or_other_Welfare_Non_Disability_Income_Maintenance_all_TANF_serices_,140% / TANF or other Welfare/Non-Disability Income Maintenance (all TANF services)ottext
%TypeRef,Unemployment_Insurance,141% / Unemployment Insuranceottext
%TypeRef,WIC,142% / WICottext
%TypeRef,Workforce_Development_WIA_,143% / Workforce Development (WIA)ottext
END
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