HMIS Data: VA SSVF INTAKE FORM FOR TEXT FIELDS, USE BLOCK LETTERS. OTHERWISE, MARK APPROPRIATE BOXES WITH AN “X” Fill out separate form for each household member and clip together. (e.g. 10/24/2014) PROGRAM ENTRY DATE [All clients] / / Month Day Year Partial, Client Client Street does refused Full or Code not to (first, middle, last name, suffix (e.g., Jr, Sr., III)) [All clients] CURRENT NAME Name Name know provide First name     Middle name     Last name Suffix VAMC STATION NUMBER (Heads of Households Only) Station Number HOUSEHOLD INCOME AS PERCENT OF AMI (Heads of Households Only) Less than 30% Greater than 50%   30% to 50%  LAST PERMANENT ADDRESS (All Adults and Heads of Household) Street Address City State Zip Code LAST PERMANENT ADDRESS DATA QUALITY (All Adults and Heads of Household) Full address completed Client does not know   Incomplete or estimated address Client refused to provide   not collected LAST GRADE COMPLETED (All Adults and Heads of Household) No schooling completed 12th grade, No diploma   Nursery school to 4th grade High school diploma   5th grade or 6th grade GED   7th grade or 8th grade Post-secondary school   9th grade Client does not know   10th grade Client refused to provide   11th grade 
HMIS Data: VA SSVF INTAKE FORM FOR TEXT FIELDS, USE BLOCK LETTERS. OTHERWISE, MARK APPROPRIATE BOXES WITH AN “X” Fill out separate form for each household member and clip together. PROGRAM ENTRY DATE (e.g. 10/24/2014) [All clients] / / Month Day Year CURRENT NAME (first, middle, last name, suffix (e.g., Jr, Sr., III)) [All clients] Full Name Partial, Street or Code Name Client does not know Client refused to provide First name     Middle name Last name     Suffix VAMC STATION NUMBER (Heads of Households Only) Station Number HOUSEHOLD INCOME AS PERCENT OF AMI (Heads of Households Only)  Less than 30%  Greater than 50%  30% to 50% LAST PERMANENT ADDRESS (All Adults and Heads of Household) Street Address City State Zip Code LAST PERMANENT ADDRESS DATA QUALITY (All Adults and Heads of Household)  Full address completed  Client does not know  Incomplete or estimated address  Client refused to provide not collected LAST GRADE COMPLETED (All Adults and Heads of Household)  No schooling completed  12th grade, No diploma  Nursery school to 4th grade  High school diploma  5th grade or 6th grade  GED  7th grade or 8th grade  Post-secondary school  9th grade  Client does not know  10th grade  Client refused to provide  11th grade
HMIS-SSVF-Intake-Form.docx