RELATIONSHIP TO HEAD OF HOUSEHOLD Head of other relation member household’s Self (head of household)   (other relation to head of household) Other: non-relation member Head of child  household’s  Head of spouse or partner  household’s RACE More than one race is permitted. Client and Client refused should only be selected if no other response is doesn’t know selected. If the client wishes to or indicate that in the next question (Ethnicity) and then indicate “Hispanic Latino,” please select the appropriate race category here. American Indian or Alaska Native White   Asian Client   doesn’t know Black or African American Client refused   Native Hawaiian or Other Pacific Islander  ETHNICITY Non-Hispanic / Non-Latino Client   doesn’t know Hispanic / Latino Client refused   GENDER Female as male, female or transgender   Doesn’t identify Male Client   doesn’t know Transgender male to female Client refused   Transgender female to male  HEALTH INSURANCE Is the client currently covered by health insurance? No Client   doesn’t know Yes Client refused    or for each health insurance source. [IF YES] Answer ‘Yes’ ‘No’ for sources that have been terminated, even if they were received in the past. Answer ‘No’ No Yes Source of non-cash benefit Medicaid Medicare Program (or use local name) State Children’s Health Insurance
RELATIONSHIP TO HEAD OF HOUSEHOLD  Self (head of household)  Head of household’s other relation member (other relation to head of household)  Head of household’s child  Other: non-relation member  Head of household’s spouse or partner RACE More than one race is permitted. Client doesn’t know and Client refused should only be selected if no other response is selected. If the client wishes to indicate “Hispanic or Latino,” please indicate that in the next question (Ethnicity) and then select the appropriate race category here.  American Indian or Alaska Native  White  Asian  Client doesn’t know  Black or African American  Client refused  Native Hawaiian or Other Pacific Islander ETHNICITY  Non-Hispanic / Non-Latino  Client doesn’t know  Hispanic / Latino  Client refused GENDER  Female  Doesn’t identify as male, female or transgender  Male  Client doesn’t know  Transgender male to female  Client refused  Transgender female to male HEALTH INSURANCE Is the client currently covered by health insurance?  No  Client doesn’t know  Yes  Client refused  [IF YES] Answer ‘Yes’ or ‘No’ for each health insurance source. Answer ‘No’ for sources that have been terminated, even if they were received in the past. No Yes Source of non-cash benefit Medicaid Medicare State Children’s Health Insurance Program (or use local name)
HMIS-Data-Collection-Form-Entry.docx