Male Client refused ○ ○ Trans Female (MTF or Male to Female) Data not collected ○ ○ Trans Male (FTM or Female to Male) ○ Gender Non-Conforming (i.e. not exclusively male or female) ○ RACE all applicable) Clients] American Indian or Alaskan Native White/Caucasian ○ ○ Asian ○ Client does not know ○ Black/African American Client refused ○ ○ Hawaiian or Other Pacific Islander Data Not Collected ○ ○ ETHNICITY​ Clients] Client does not know ○ ○ Client refused ○ Data Not Collected ○ Hispanic/Latino ○ Other ○ VETERAN STATUS​ Adults] Client doesn’t know No ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO VETERAN STATUS “YES” Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ Theater of Operations: Korean War No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ Theater of Operations: Vietnam War No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○ Theater of Operations: Persian Gulf War (Desert Storm) No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ Theater of Operations: Afghanistan (Operation Enduring Freedom) No Client doesn’t know ○ ○ Yes Client refused ○ ○
○ Male ○ Client refused ○ Trans Female (MTF or Male to Female) ○ Data not collected ○ Trans Male (FTM or Female to Male) ○ Gender Non-Conforming (i.e. not exclusively male or female) RACE all applicable) Clients] ○ American Indian or Alaskan Native ○ White/Caucasian ○ Asian ○ Client does not know ○ Black/African American ○ Client refused ○ Hawaiian or Other Pacific Islander ○ Data Not Collected ETHNICITY​ Clients] ○ ○ Client does not know ○ Client refused ○ Hispanic/Latino ○ Data Not Collected ○ Other VETERAN STATUS​ Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO VETERAN STATUS Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Korean War ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Vietnam War ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Persian Gulf War (Desert Storm) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Afghanistan (Operation Enduring Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client refused
PATH-Project-Intake-HMIS-2017-rev14Sept17.docx