1. Information Name and/or Alias SSN ID 2. Information Type Head of Relationship to Head of 3. Entry Summary Provider Name Couple (parent & friend) & child(ren) Couple with no child(ren) Extended family unit Name Data SSN Data U.S. Military Veteran? Foster parent(s) with child(ren) Grandparent(s) with child(ren) n-custodial caregiver(s) with child(ren) If No, HoH Name & ID Brother Granddaughter Daughter Grandfather Daughter-in-law Grandmother Father Grandson Father-in-law Husband Foster daughter Mother Foster Son Mother-in-law Full Name Reported Partial, Street Name, or Code Name Reported Full SSN Reported Approximate or Partial SSN Reported Nephew Niece Other non-relative Other relative Self Significant other Sister Entry Type Other Single parent with child(ren) Two parents with child(ren) Son-in-law Step-daughter Step-son Unknown Wife HUD/Other VA PATH RHY Entry Date 4. Universal Data Elements All Members Entering Yes ***Record Initial Date of CONTACT, including location*** Date of Birth Race Pri Sec American Indian/Alaska Native Asian Black or African-American Native Hawaiian/Pacific Islander White Gender Male Female Transgender Male to Female Transgender Female to Male Other of Long Duration DOB Data Ethnicity If Other Gender, Specify Full DOB Reported Partial DOB Reported n-hispanic/latino Hispanic/Latino Rev. 10/1/2015 Page 1 of 5
Type of Residence Prior to Program Entry If Other Type of Residence, Specify Relationship to HoH Homeless Primary Reason entering from the streets, ES or SH Regardless of where they stayed last night Number of times the client has been on the streets, in ES or SH in the past three years including today Length of time homeless - Status Documented? Emergency shelter, including voucher Foster care home or foster care group home Hospital (non-psychiatric) Hotel or motel paid for without voucher Jail, prison or juvenile detention facility Long-term care facility or nursing home Owned by client, no housing subsidy Owned by client, with housing subsidy Permanent housing for formerly homeless Place not meant for habitation Psychiatric hospital/facility Rental by client, no housing subsidy Rental by client, with VASH housing subsidy Rental by client, with GPD TIP subsidy Rental by client, with other housing subsidy Residential project/halfway house Safe Haven Staying or living with a family member Staying or living with a friend Substance abuse treatment facility/detox Transitional housing for homeless persons Other Doesn't Know Self (Head of ) Head of s child Head of s spouse or partner Head of s other relation member Other: non-relation member Aged out of foster care doesn t know NOT homeless refused Criminal Activity Data not collected Never in 3 years One time Two times Three times Four or more times Length of Stay in Previous Place Zip Code of Last Perm Residence Location Domestic Violence Economic Evicted Family dispute/overcrowding Loss of job Medical condition If Yes for entering from streets, ES or SH Approx. Date Started Total number of months homeless on the street, in ES or SH in the past three years One day or less Two days to one week More than one week, less than one month One to three months More than three months, less than one year One year or longer AZ-502 Mental health Moved to seek work Natural disaster/fire Release from jail or prison Relocated Substance abuse Trafficking/Exploitation One month (this time is the first month) 2 3 4 5 6 7 8 9 10 11 12 More than 12 months Rev. 10/1/2015 Page 2 of 5
5. Program Data Elements Housing Category 1 - Homeless Status Category 2 - At Imminent Risk of Losing Housing Category 3 - Homeless only under other federal statutes Category 4 - Fleeing Domestic Violence At Risk of Homelessness Stably Housed Income and Benefits Total Monthly Income Income from any source Sources and Amounts of Income at Entry Alimony or Other Spousal Support Child Support Earned Income General Assistance No Financial Resources Other Pension or Retirement Former Job Private Insurance Retirement Income Social Security SSDI SSI TANF Tribal Pay Unemployment Insurance VA Non-Service Pension VA Service Connected Comp Worker's Compensation If Other, Please Specify Covered by Health Insurance Alcohol Abuse Un; presumptive or self-report Confirmed through assessment & clinical eval Confirmed by prior eval or clinical records WIC Non-cash benefit from any source Health Insurance Health Insurance Type Disabilities Non-Cash Benefits Supplemental Nutrition Assist Program (Food Stamps) Special Supplemental Nutrition Program for TANF Child Care Services TANF Transportation Services Other TANF-Funded Services Section 8, Public Housing Other Source Temporary Rental Assistance MEDICAID MEDICARE State Children s Health Insurance Program Veteran's Administration (VA) Medical Services Employer Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Un; presumptive or self-report Confirmed through assessment & clinical eval Confirmed by prior eval or clinical records Yes Rev. 10/1/2015 Page 3 of 5
Chronic Health Condition Yes Developmental Yes Drug Abuse Un; presumptive or self-report Confirmed through assessment & clinical eval Confirmed by prior eval or clinical records Un; presumptive or self-report Confirmed through assessment & clinical eval Confirmed by prior eval or clinical records Yes HIV/AIDS Yes Rev. 10/1/2015 Page 4 of 5
Mental Health Problem Un; presumptive or self-report Confirmed through assessment & clinical eval Confirmed by prior eval or clinical records Un; presumptive or self-report Confirmed through assessment & clinical eval Confirmed by prior eval or clinical records Yes Physical Yes Highest Level of Education Attained Schooling Completed Nursery School to 4 th Grade 5 th or 6 th Grade 7 th or 8 th Grade 9 th Grade 10 th Grade 11 th Grade 12 th Grade, No Diploma High School Diploma GED Education Post-Secondary School, no degree Associates Degree Bachelors Masters Doctorate Other Graduate/Professional Degree Certificate of advanced training PATH Status ***Record Date of ENGAGEMENT when appropriate*** Date of PATH Status Determination If no, reason not enrolled was found ineligible for PATH was not enrolled for other reason(s) became enrolled in PATH Connection with SOAR Intake Staff Name Acknowledgement Signed Rev. 10/1/2015 Page 5 of 5