Colorado Springs/El Paso County - HOH and Adult CIS Data Entry Form
Account Profile / HH Members / Start Date: / /Client Name (All clients): First: ______Middle: ______Last: Suffix
Name Data Quality (Agency Use Only)q Full name reported / q Partial, street name, or code name reported / q Client doesn’t know / q Client refused
Date of Birth (mm/dd/yyyy) (All clients): / /
DOB Data Quality (Agency Use Only)q Full DOB reported / q Approximate or Partial DOB reported / q Client doesn’t know / q Client refused
Social Security Number (All clients): ______
SSN Data Quality (Agency Use Only)q Full SSN reported / q Approximate or Partial SSN reported / q Client doesn’t know / q Client refused
Contact Information (Head of Household):
Phone # / Phone Type: / q Home / q Cell / q Work / q MessageEmail address
Last Known Permanent Address (where you last lived for 90 days or more) (All clients):
Address ______City: / County: ______/ State: / Zip Code:
Address Data Quality (Agency Use Only):
q Full address reported / q Incomplete or estimated address / q Client doesn’t know / q Client refused
HH Members
Household Type (Head of Household) (Agency Use Only):
q Households without children / q Households with at least one adult and one child / q Households with only children
Housing Status (Optional) (Agency Use Only):
q Category 1 - Homeless / q Category 2 - At imminent risk of losing housing / q Category 3 - Homeless only under other federal statutes
q Category 4 - Fleeing domestic violence / q At-risk of homelessness / q Stably housed
q Client doesn’t know / q Client refused
Relationship to Head of Household (All clients):
q Self (Head of Household) / q Head of Household’s child / q Head of Household’s spouse or partnerq Head of Household’s other relation member / q Other: non-relation member
Gender (All clients):
q Female / q Male / q Trans Female (MTF or Male to Female) / q Trans Male (FTM or Female to Male)q Gender Non-Conforming (i.e not exclusively male or female) / q Client doesn’t know / q Client refused
Do you have a Disabling Condition? (All clients)
q No / q Yes / q Client doesn’t know / q Client refusedAre you a Veteran? Have you Served/Serving in the U.S. Military? (Adults Only)
q No / q Yes / q Client doesn’t know / q Client refusedEthnicity (All clients)
q Non-Hispanic/Non-Latino / q Hispanic/Latino / q Client doesn’t know / q Client refusedRace – check all that apply, but at least one (All clients):
q American Indian or Alaska Native / q Asian / q Black or African American / q Client refusedq Native Hawaiian or Other Pacific Islander / q White / q Client doesn’t know
Income and Sources (Head of household and adults)
Income from any source? / q No Financial Resourcesq Client doesn’t know q Client refused
(If yes, indicate all sources and dollar amounts for the sources that apply)
Earned Income (employment income) / q Yes / (if yes) monthly amount $ .
Unemployment Insurance / q Yes / (if yes) monthly amount $ .
Supplemental Security Income (SSI) / q Yes / (if yes) monthly amount $ .
Social Security Disability Income (SSDI) / q Yes / (if yes) monthly amount $ .
VA Service-Connected Disability Compensation / q Yes / (if yes) monthly amount $ .
VA Non-Service-Connected Disability Pension / q Yes / (if yes) monthly amount $ .
Private Disability Insurance / q Yes / (if yes) monthly amount $ .
Worker’s Compensation / q Yes / (if yes) monthly amount $ .
Temporary Assistance for Needy Families (TANF) / q Yes / (if yes) monthly amount $ .
General Assistance (GA) / q Yes / (if yes) monthly amount $ .
Retirement Income from Social Security / q Yes / (if yes) monthly amount $ .
Pension or Retirement Income from a former job / q Yes / (if yes) monthly amount $ .
Child Support / q Yes / (if yes) monthly amount $ .
Alimony or other spousal support / q Yes / (if yes) monthly amount $ .
Other source / q Yes / (if yes) monthly amount $ .
(if other source) Specify source
Total Monthly Income / $ .
Non-Cash benefits (Head of household and adults):
Non-Cash benefit from any source? / q Yes q No q Client doesn’t know q Client refused(If yes, indicate all sources that apply)
q Supplemental Nutrition Assistance Program (SNAP) $______/ q Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
q TANF Child Care services / q Other TANF-funded services
q TANF transportation services / q Other source ______
Health Insurance (All clients):
Covered by Health Insurance? / q Yes q No q Client doesn’t know q Client refused(If yes, indicate all sources that apply)
q Medicaid______/ q Medicare______/ q VA Medical Services
q State Children’s health Insurance / q Employer-Provided / q COBRA Health Insurance
q Private Pay Health Insurance / q State Health Insurance for Adults / q Indian health service program
q Other______
COC_Entry_Questions (Head of Household ONLY)
Reasons or Contributing Factors to Homelessness (choose all that apply):
q Abuse or Violence in My Home / q Lost a Job Could not Find Workq Alcohol Substance Abuse Problems / q Medical Expenses
q Asked to Leave / q Mental Illness
q Bad Credit / q Moved to Find Work
q Could Not Pay Utilities / q Problems with Public Benefits
q Discharge from Foster Care / q Reasons Related to My Sexual Orientation
q Discharged from Jail / q Relationship Problems or Family Break-up
q Discharged from Prison / q Unable to Pay Rent Mortgage
q Does not Apply to Me / q Client doesn’t know
q Family Member or Personal Illness / q Client refused
q Legal Problems / q Other:
Did you relocate to Colorado/Colorado Springs? / q No / q Yes
If you relocated to Colorado/Colorado Springs, why? (select all that apply)
q Care of sick relative / q Climate / q Colorado marijuana laws / q Domestic Violence
q Driver’s Licenses/ID for immigrants / q Employment / q Family Support / q Medical Needs
q Natural Disaster / q Needed services
Program Specific
Type of Residence (Prior Living Situation – where you stayed last night)
Literally Homelessq Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) / q Safe Haven
q Emergency shelter, including hotel or motel paid for with emergency shelter voucher / q Interim Housing
Institutional Situation
q Foster care home or foster care group home / q Long-term care facility or nursing home
q Hospital or other residential non-psychiatric medical facility / q Psychiatric hospital or other psychiatric facility
q Jail, prison, or juvenile detention facility / q Substance abuse treatment facility or detox center
Transitional & Permanent Housing Situation
q Hotel or motel paid for without emergency shelter voucher / q Rental by client, with other ongoing housing subsidy (including RRH)
q Owned by client, no ongoing housing subsidy / q Residential project or halfway house with no homeless criteria
q Owned by client, with ongoing housing subsidy / q Staying or living in a family member’s room, apartment, or house
q Permanent housing (other than RRH) for formerly homeless persons / q Staying or living in a friend’s room, apartment, or house
q Rental by client, no ongoing housing subsidy / q Transitional housing for homeless persons (including homeless youth)
q Rental by client, with VASH subsidy / q Rental by client, with GPD TIP subsidy
Other Situations
q Client doesn’t know / q Client refused
ANSWER NEXT QUESTION ONLY IF:
· Your Type of Residence (checked above) is Institutional Situation and your Length of Stay is less than 90 days… OR
· Your Type of Residence (checked above) is Transitional & Permanent Supportive Housing Situation and your Length of Stay is less than 7 days…
On the night before this situation, did you stay on the streets, in an Emergency Shelter or Safe Haven?
q No / q YesANSWER NEXT QUESTIONS ONLY IF:
· Your Type of Residence is Literally Homeless… OR
· You answered Yes to the previous question…
Approximate date homelessness started? / ______/______/______Regardless of where you stayed last night – Total number of times the client has been homeless on the streets, in Emergency Shelter, or Safe Haven in the past three years including today? / q One Time q Two times q Three times
q Four or more times
q Client doesn’t know q Client refused
q Data Not Collected
Total number of months homeless on the streets, in Emergency Shelter, or Safe Haven in the past three years? / q One month (this is the first time)
q 2 q 3 q 4 q 5 q 6 q 7 q 8 q 9 q 10 q 11 q 12 q More than 12
q Client doesn’t know q Client refused
q Data Not Collected
Length of Stay in Prior Living Situation (where you stayed last night):
q One night or less / q Two to six nights / q One week or more, but less than one monthq One month or more, but less than 90 days / q 90 days or more, but less than one year / q One year or longer
q Client doesn’t know / q Client refused
Housing Move-in Date (mm/dd/yyyy): PSH programs only – All Clients (Agency Use Only) / /
Do you have a Physical Disability? / q No / q Yes / q Client doesn’t know / q Client refused
If Yes, Is the physical disability expected to be of long-continued and indefinite duration and substantially impair the ability to live independently? / q No / q Yes / q Client doesn’t know / q Client refused
Do you have a Developmental Disability? / q No / q Yes / q Client doesn’t know / q Client refused
If Yes, Does the developmental disability substantially impair ability to live independently? / q No / q Yes / q Client doesn’t know / q Client refused
Do you have a Chronic Health Condition? / q Yes / q No / q Client doesn’t know / q Client refused
If Yes, is chronic health condition expected to be of long-continued and indefinite duration and substantially impair the ability to live independently? / q Yes / q No / q Client doesn’t know / q Client refused
Have you been diagnosed with AIDS or have you tested positive for HIV? / q No / q Yes / q Client doesn’t know / q Client refused
If Yes, is HIV/AIDS expected to substantially impair ability to live independently? / q No / q Yes / q Client doesn’t know / q Client refused
Do you have Mental Health Problems? / q No / q Yes / q Client doesn’t know / q Client refused
If Yes, is the mental health problem expected to be of long, continued and indefinite duration and substantially impair ability to live independently? / q No / q Yes / q Client doesn’t know / q Client refused
Do you have a drug or alcohol problem? / q No / q Alcohol abuse / q Drug abuse
q Both alcohol and drug abuse / q Client doesn’t know / q Client refused
If Yes, is substance abuse problem expected to be of long-continued and indefinite duration and substantially impair the ability to live independently? / q No / q Yes / q Client doesn’t know / q Client refused
Domestic Violence (Head of household and adults):
Domestic Violence victim/survivor? / q No / q Yes / q Client doesn’t know / q Client refusedq Data Not Collected
If yes for Domestic Violence victim/survivor, when did experience occur? / q Within past three months q Three to six months ago
q Six months to one year ago q One year ago or more
q Client doesn’t know q Client refused q Data Not Collected
If yes for Domestic Violence victim/survivor, Are you currently fleeing? / q No q Yes q Client doesn’t know q Client refused
q Data Not Collected
Client Signature: Date:
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2017 HUD Data Standards 12/7/2017