No doesn’t know Are you currently fleeing? Client refused Yes Data not collected INCOME FROM ANY SOURCE of Household and Adults] No Client doesn’t ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY “YES” – Income Source Amount Income Source Alimony and Other Spousal Support Child support ○ ○ Pension or Retirement income from former job Earned Income ○ ○ Retirement Income from Social Security General Assistance (GA) ○ ○ Social Security Disability Insurance (SSDI) Private Disability Insurance ○ ○ Supplemental Security Income (SSI) Unemployment Insurance ○ ○ TANF (Temporary Assist for Families) Worker’s Compensation ○ ○ VA Service Connected Disability Other source ○ ○ Compensation VA Connected Disability Pension Other (specify): ○ Total monthly amount: RECEIVING BENEFITS​ of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO BENEFITS INDICATE ALL SOURCES THAT APPLY “YES” – ○ Supplemental Nutrition Assistance Program (SNAP) TANF Childcare Services ○ Special Supplemental Nutrition Program for Women, ○ TANF Transportation Services ○ Infants, and Children (WIC) ○ (Specify): Other TANF-funded services ○ COVERED BY HEALTH INSURANCE Clients] No Client doesn’t ○ ○ Client refused ○ Yes ○ Data not ○ IF TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS “YES” MEDICAID Employer Provided Health ○ ○ MEDICARE Insurance Obtained through ○ ○ State Children’s Health Insurance (SCHIP) Private Pay Health Insurance ○ ○ Veteran’s Administration (VA) Medical Services State Health Insurance for Adults ○ ○ Other (specify) Indian Health Services Program ○ ○ CONTACT INFORMATION [Optional- can be entered in Location Tab]
Are you currently fleeing? No doesn’t know Yes Client refused Data not collected INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source ○ Alimony and Other Spousal Support ○ Child support ○ Pension or Retirement income from former job ○ Earned Income ○ Retirement Income from Social Security ○ General Assistance (GA) ○ Social Security Disability Insurance (SSDI) ○ Private Disability Insurance ○ Supplemental Security Income (SSI) ○ Unemployment Insurance ○ TANF (Temporary Assist for Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension Other (specify): Total monthly amount: RECEIVING BENEFITS​ of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO BENEFITS – INDICATE ALL SOURCES THAT APPLY ○ Supplemental Nutrition Assistance Program (SNAP) ○ TANF Childcare Services ○ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) ○ TANF Transportation Services ○ (Specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE Clients] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not IF “YES” TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health ○ MEDICARE ○ Insurance Obtained through ○ State Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ State Health Insurance for Adults ○ Other (specify) ○ Indian Health Services Program CONTACT INFORMATION [Optional- can be entered in Location Tab]