Race American Indian or Alaska Native Native Hawaiian/Pacific Islander Client doesn’t know Client Refused (select up to Asian White 2) Black or African American Female Gender Transgender female to male Client doesn’t know Male (select one) Doesn’t identify as male, female or transgender Client refused Transgender male to female Have a disability of long duration? Yes No Client doesn’t know Client refused Self (head of household) Other: Non-relation member Relationship Head of Household’s Child Client doesn’t know to Head of Head of Household’s spouse or partner Client refused Household Head of Household’s other relation member Yes No If yes, enter type Covered by Health Insurance I.E. Medicaid, etc. Child –Please complete for any children in your household (1 child per table) First Name MI Last Name Social Security Number(SSN) Date of Birth Ethnicity Non-Hispanic/Non-Latino Hispanic/Latino Client refused (DOB) Client doesn’t know Race American Indian or Alaska Native Native Hawaiian/Pacific Islander (select up to Asian White Client Refused 2) Black or African American Female Gender Transgender female to male Client doesn’t know Male (select one) Doesn’t identify as male, female or transgender Client refused Transgender male to female Have a disability of long duration? Yes No Client doesn’t know Client refused Self (head of household) Other: Non-relation member Relationship Head of Household’s Child Client doesn’t know to Head of Head of Household’s spouse or partner Client refused Household Head of Household’s other relation member Yes No If yes, enter type Covered by Health Insurance I.E. Medicaid, etc. Child –Please complete for any children in your household (1 child per table) First Name MI Last Name Social Security Number(SSN) Date of Birth Ethnicity Non-Hispanic/Non-Latino Hispanic/Latino Client refused (DOB)
Race (select up to 2) American Indian or Alaska Native Asian Black or African American Native Hawaiian/Pacific Islander White Client doesn’t know Client Refused Gender (select one) Female Male Transgender male to female Transgender female to male Doesn’t identify as male, female or transgender Client doesn’t know Client refused Have a disability of long duration? Yes No Client doesn’t know Client refused Relationship to Head of Household Self (head of household) Head of Household’s Child Head of Household’s spouse or partner Head of Household’s other relation member Other: Non-relation member Client doesn’t know Client refused Covered by Health Insurance I.E. Medicaid, etc. Yes No If yes, enter type Child –Please complete for any children in your household (1 child per table) First Name MI Last Name Social Security Number(SSN) Date of Birth (DOB) Ethnicity Non-Hispanic/Non-Latino Hispanic/Latino Client refused Race (select up to 2) American Indian or Alaska Native Asian Black or African American Native Hawaiian/Pacific Islander White Client doesn’t know Client Refused Gender (select one) Female Male Transgender male to female Transgender female to male Doesn’t identify as male, female or transgender Client doesn’t know Client refused Have a disability of long duration? Yes No Client doesn’t know Client refused Relationship to Head of Household Self (head of household) Head of Household’s Child Head of Household’s spouse or partner Head of Household’s other relation member Other: Non-relation member Client doesn’t know Client refused Covered by Health Insurance I.E. Medicaid, etc. Yes No If yes, enter type Child –Please complete for any children in your household (1 child per table) First Name MI Last Name Social Security Number(SSN) Date of Birth (DOB) Ethnicity Non-Hispanic/Non-Latino Hispanic/Latino Client refused
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