COHMIS Intake Form For project type: Transitional Housing, Permanent Housing, Rapid Re-Housing, Service Only, Day Shelter, Homelessness Prevention, and Coordinated Assessment PROJECT START DATE​ Clients] Month Day Year SOCIAL SECURITY NUMBER​ Clients] QUALITY OF SOCIAL SECURITY Client doesn’t know ○ Full SSN reported ○ Client refused ○ Approximate or partial SSN reported Data not collected ○ ○ CURRENT NAME Clients] N/A Last First Middle ○ Suffix ○ Alias ○ QUALITY OF CURRENT NAME Full name reported ○ Client doesn’t know ○ ○ Client refused Partial, street name, or code name reported ○ ○ Data not collected DATE OF Clients] Age: Month Day Year QUALITY OF DATE OF BIRTH Full DOB reported Client doesn’t know ○ ○ Client refused ○ Approximate or partial DOB reported ○ Data not collected ○ GENDER​ Clients] ○ Female ○ Client doesn’t know ○ Male ○ Client refused ○ Trans Female (MTF or Male to Female) ○ Data not collected ○ Male (FTM or Female to Male) ○ Gender Non-Conforming (i.e. not exclusively male or female) RACE all applicable) Clients]
COHMIS Intake Form For project type: Transitional Housing, Permanent Housing, Rapid Re-Housing, Service Only, Day Shelter, Homelessness Prevention, and Coordinated Assessment PROJECT START DATE​ Clients] Month Day Year SOCIAL SECURITY NUMBER​ Clients] QUALITY OF SOCIAL SECURITY ○ Full SSN reported ○ Client doesn’t know ○ Client refused ○ Approximate or partial SSN reported ○ Data not collected CURRENT NAME Clients] N/A Last First Middle ○ Suffix ○ Alias ○ QUALITY OF CURRENT NAME ○ Full name reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client refused ○ Data not collected DATE OF Clients] Age: Month Day Year QUALITY OF DATE OF BIRTH ○ Full DOB reported ○ Client doesn’t know ○ Approximate or partial DOB reported ○ Client refused ○ Data not collected GENDER​ Clients] ○ Female ○ Client doesn’t know ○ Male ○ Client refused ○ Trans Female (MTF or Male to Female) ○ Data not collected ○ Male (FTM or Female to Male) ○ Gender Non-Conforming (i.e. not exclusively male or female) RACE all applicable) Clients]