Intake (Utilization) Reportreport Definition

Intake (Utilization) ReportReport Definition

This report prints very detailed data about a selected client, the client’s household members, addresses and phone

numbers. Employment information is also displayed here along with the client’s income that was used to approve or

deny their application. Any services or programs received by the client is captured here containing payments made

and vendor information. This form also contains client characteristic data and dwelling / heat type information.

The data fields are defined below.

Generation of Data:

• Dynamically – pulled from the database after it has been entered into OPUS
• Manually – this data is written or typed on the form after it has been printed.
• By Calculation – values calculated using other values from the database.

General Information
Data Field Name / Data Is
Generated… / Data Description
Authorization # / Dynamically / The number that is assigned to the client for each payment by the Intake worker. This number can also be manually entered into the data base by the intake worker. If the client has received multiplepayments ie. regular and crisis then the crisis payment authorization number is displayed here. If the client only received one regular payment then this field will be blank.
Applicant Name / Dynamically / The name of the client applying for energy assistance.
Program / Dynamically / The name of the program the authorization form is for.
Agency / Dynamically / The name of the agency that worked with the selected client.
Client Information
Data Field Name / Data Is
Generated… / Data Description
Household Type / Dynamically / The household type describes the characteristics of the family that lives in the residence. See attachment A for possible values.
Total Number in Household / Dynamically / This is the total number of people living within the household of the selected client.
Name / Dynamically / The name of the client and all other household members.
DOB / Dynamically / The birth date of the client and all other household members.
SSN/ID # / Dynamically / The social security number / other identification number of the client and all other household members.
SSN Vrfd? / Dynamically / Flag to determine of the SSN of the client has been verified.
Adult Vrfd? / Dynamically / Flag to determine if the client has been verified to be an adult.
GENDER (GN) / Dynamically / The gender of the client and all other household members. Possible Values are: M (Male), F (Female) and U (Unknown).
ET / Dynamically / The ethnicity of the client and all other household members. See attachment A for possible values.
Race / Dynamically / The race of the client
OTR / Dynamically / Tribal affiliation of the client
ED / Dynamically / The greatest education level of the client and all other household members. See attachment A for possible values.
DS / Dynamically / This specifies the disability status of the client and all other household members. Possible values are: Y (yes) and N (no).
HB / Dynamically / This specifies if the client or any other household members are homebound. The homebound definition in this case is unable to leave the residence for a number of medical reasons. Possible values are: Y (yes) and N (no).
VT / Dynamically / This specifies the veteran status of the client and all other household members. Possible values are: Y (yes) and N (no).
NCB / Dynamically / Non-cash benefit of the client
Phone
Data Field Name / Data Is
Generated… / Data Description
Phone / Dynamically / This lists all contact numbers for the client.
Extension / Dynamically / This lists all extensions to contact numbers for the client.
Type / Dynamically / This describes the type of contact number. See attachment A for possible values.
Addresses
Data Field Name / Data Is
Generated… / Data Description
Address / Dynamically / Mailing address of the client
County / Dynamically / County of the client
Residence
Data Field Name / Data Is
Generated… / Data Description
Address / Dynamically / Physical Address of the client
County / Dynamically / County of the client
Type of Dwelling / Dynamically / This displays the type of residence the client lives in ie. house, mobile home. See attachment A for possible values.
Residence Status / Dynamically / This displays the status of the residence ie. rent, own. See attachment A for possible values.
Primary Heat Type / Dynamically / This is the main source of heat used within the residence. Possible values are listed in the rows below. See attachment A for heat type codes.
Electric / Dynamically / This specifies if the residence uses electric heat or not. Possible values are: Y (yes) and N (no).
Wood / Dynamically / This specifies if the residence uses wood to produce heat or not. Possible values are: Y (yes) and N (no).
Natural Gas / Dynamically / s specifies if the residence uses natural gas heat or not. Possible values are: Y (yes) and N (no).
Solar / Dynamically / This specifies if the residence uses solar sources to produce heat or not. Possible values are: Y (yes) and N (no).
Pellet / Dynamically / This specifies if the residence uses pellet heat or not. Possible values are: Y (yes) and N (no).
Oil / Dynamically / This specifies if the residence uses oil heat or not. Possible values are: Y (yes) and N (no).
Liquid Gas / Dynamically / This specifies if the residence uses liquid gas/propane heat or not. Possible values are: Y (yes) and N (no).
Other / Dynamically / This specifies if the residence uses other sources of heat or not. Possible values are: Y (yes) and N (no).
Comments
Data Field Name / Data Is
Generated… / Data Description
Comments / Dynamically / Comments for the household
Employment
Data Field Name / Data Is
Generated… / Data Description
Ref / Dynamically / This is the same as the SSN/ID # which is the social security number / other identification number for the client and other household members.
Employer / Dynamically / The name of the employer for the client and other household members.
Address / Dynamically / The physical address of the employer.
Phone / Dynamically / The phone number of the employer.
Extension / Dynamically / The extension number at which the employer can be reached.
Income
Data Field Name / Data Is
Generated… / Data Description
Ref / Dynamically / This is the same as the SSN/ID # which is the social security number / other identification number for the client and other household members.
Income Source / Dynamically / The source of the income for the client and other household
members. This could be the name of a business, NONE, or type ie. sales. This is a free-form field and does not have pre set values to select from.
Type / Dynamically / The type of income the client and other household members receive. See attachment B or possible values.
Frequency / Dynamically / This describes how often the client and other household members receive income from the specific sources. See attachment B for possible values.
Amount / Dynamically / This is the dollar amount the client and other household members receive from their income source individually.
Annual / By Calculation / This is the total annual amount the client and other household members receive from their income source.
Comments / Verification / Dynamically / This displays comments or notes that the intake worker has made regarding the sources of income for the client and other household members.
Applicant Disclaimer
Data Field Name / Data Is
Generated… / Data Description
Approved / Manually / This specifies if the application for energy assistance has been approved. This is typically done with a checkmark in the field.
Denied / Manually / This specifies if the application for energy assistance has been denied. This is typically done with a checkmark in the field.
Applicant Signature(1) / Manually / This is the signature of the primary client applying for energy assistance.
Applicant Date(1) / Manually / This is the date in which the primary client applying for energy assistance signed this form.
Applicant Signature(2) / Manually / This is the signature of the co-applicant applying for energy assistance.
Applicant Date(2) / Manually / This is the date in which the co-applicant applying for energy assistance signed this form.
Intake Worker Signature / Manually / This is the signature of the worker that reviewed the application of the client for energy assistance.
Intake Signature Date / Manually / This is the date in which the intake worker signed this form.
Authorizing Agency Signature / Manually / This is the signature of the agency head that verified the application of the client for energy assistance.
Authorizing Agency Date / Manually / This is the date in which the agency head signed this form.
Data Entry Signature / Manually / This is the signature of the person responsible for the data entry of the application contents.
Data Entry Signature Date / Manually / This is the date in which the data entry person signed this form.
Program
Data Field Name / Data Is
Generated… / Data Description
Program / Dynamically / This is the full program name that the client received as a service.
Weatherization / Dynamically / This specifies if the client has received weatherization services. Possible values are: Y (Yes) and N (No).
Subsidized / Dynamically / This specifies if the client receives any subsidy assistance for rent. Possible values are: Y (Yes) and N (No).
Annual Income / Dynamically / This is the grand total annual amount the client and other household members receive combined from their income source(s).
Vendor / Dynamically / The utility vendor name(s) for the client in which assistance payments are being made
Name on Account / Dynamically / The name on the utility account for the client.
Account # / Dynamically / The account number assigned by the vendor to the client for utility services.
Amount / Dynamically / The amount of each payment made to the vendor(s) on behalf of the client.
Comments / Dynamically / This displays comments that the intake worker has made regarding the verification of utility information of the client and other household members.
Vendor
Data Field Name / Data Is
Generated… / Data Description
Vendor / Dynamically / Name of the Vendor
Name on Account / Dynamically / Name associated with the account
Account # / Dynamically / Account Number
Account Status / Dynamically / Status of the account
Amount / Dynamically / Payment amount
Verification/Comments / Dynamically / Comments