Is client a US Military Veteran? Yes No   If Yes to Military Veteran,” has client ever received health care benefits from a VA Center? Yes No   “US Is client receiving Veterans Services? Yes No   Is client eligible for Veterans Services? Yes No   If No to for Veterans services,” please select Reason: “eligible Client not interested Client doesn’t know Data not collected    Please select discharge type for all persons who answered Yes to Military Veteran” and are not currently serving: “US Full DOB reported Client doesn’t know   Date of Birth: / / Date of Birth Type: Approximate or partial DOB reported Client refused   Data not collected  Race: (client can choose up to 5 categories) American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Client doesn’t know    Asian White Client refused    Black or African American Data not collected   (choose one): Non Hispanic/Non-Latino Hispanic/Latino Client doesn’t know Client refused Data not collected Ethnicity:      Gender: Female Male Transgender male to female Transgender female to male Data not collected      Client doesn’t know Client refused Does not identify as female, male, or transgender    This form can be found on the NH-HMIS website at .
Is client a US Military Veteran?  Yes  No If Yes to “US Military Veteran,” has client ever received health care benefits from a VA Center?  Yes  No Is client receiving Veterans Services?  Yes  No Is client eligible for Veterans Services?  Yes  No If No to “eligible for Veterans services,” please select Reason:  Client not interested  Client doesn’t know  Data not collected Please select discharge type for all persons who answered Yes to “US Military Veteran” and are not currently serving:  Full DOB reported  Client doesn’t know Date of Birth: / / Date of Birth Type:  Approximate or partial DOB reported  Client refused  Data not collected Race: (client can choose up to 5 categories)  American Indian or Alaska Native  Native Hawaiian or Other Pacific Islander  Client doesn’t know  Asian  White  Client refused  Black or African American  Data not collected Ethnicity: (choose one):  Non Hispanic/Non-Latino  Hispanic/Latino  Client doesn’t know  Client refused  Data not collected Gender:  Female  Male  Transgender male to female  Transgender female to male  Data not collected  Client doesn’t know  Client refused  Does not identify as female, male, or transgender This form can be found on the NH-HMIS website at .