 Client refused DEVELOPMENTAL DISABILITY Does the client currently have a developmental disability? No Client   doesn’t know Yes Client refused    [IF YES for developmental disability] Is the developmental disability expected to substantially impair the to live independently? client’s ability No Client   doesn’t know Client refused  Yes  [IF YES for developmental disability] Is documentation of the disability and severity on file?  No [IF YES for developmental disability] Is the client currently receiving services/treatment for this disability? No Client   doesn’t know Client refused  Yes  CHRONIC HEALTH CONDITION Does the client currently have a chronic health condition?  No  Client doesn’t know Yes  Client refused  [IF YES for chronic health condition] Is the chronic health condition expected to be of and indefinite duration and substantially impair the to live independently? client’s ability No Client   doesn’t know Client refused  Yes  [IF YES for chronic health condition] Is documentation of the disability and severity on file?  No [IF YES for chronic health condition] Is the client currently receiving services/treatment for this condition?  No  Client doesn’t know
 Client refused DEVELOPMENTAL DISABILITY Does the client currently have a developmental disability?  No  Client doesn’t know  Yes  Client refused  [IF YES for developmental disability] Is the developmental disability expected to substantially impair the client’s ability to live independently?  No  Client doesn’t know  Yes  Client refused [IF YES for developmental disability] Is documentation of the disability and severity on file?  No [IF YES for developmental disability] Is the client currently receiving services/treatment for this disability?  No  Client doesn’t know  Yes  Client refused CHRONIC HEALTH CONDITION Does the client currently have a chronic health condition?  No  Client doesn’t know Yes  Client refused  [IF YES for chronic health condition] Is the chronic health condition expected to be of and indefinite duration and substantially impair the client’s ability to live independently?  No  Client doesn’t know  Yes  Client refused [IF YES for chronic health condition] Is documentation of the disability and severity on file?  No [IF YES for chronic health condition] Is the client currently receiving services/treatment for this condition?  No  Client doesn’t know
HMIS-Data-Collection-Form-Exit.docx