CLARITY HMIS: VA SERVICES INTAKE FORM (HUD VASH, SSVF, GPD) Use block letters for text and bubble in the appropriate circles. Please complete a separate form for each household member. PROJECT START DATE​ [All Clients] Month Day Year SOCIAL SECURITY NUMBER​ [All Clients] QUALITY OF SOCIAL SECURITY Client doesn’t know ○ Full SSN reported ○ Client refused ○ Approximate or partial SSN reported Data not collected ○ ○ CURRENT NAME Clients] Last First Middle Suffix QUALITY OF CURRENT NAME Full name reported Client doesn’t know ○ ○ Client refused ○ Partial, street name, or code name reported ○ Data not collected ○ DATE OF BIRTH​ Clients] Age: Day Year QUALITY OF DATE OF Full DOB reported Client doesn’t know ○ ○ Client refused ○ Approximate or partial DOB reported ○ Data not collected ○ GENDER​ Clients] Female Client doesn’t know ○ ○ Male Client refused ○ ○ Female (MTF or Male to Female) Data not collected ○ ○
CLARITY HMIS: VA SERVICES INTAKE FORM (HUD VASH, SSVF, GPD) Use block letters for text and bubble in the appropriate circles. Please complete a separate form for each household member. PROJECT START DATE​ Clients] Month Day Year SOCIAL SECURITY NUMBER​ Clients] QUALITY OF SOCIAL SECURITY ○ Full SSN reported ○ Client doesn’t know ○ Client refused ○ Approximate or partial SSN reported ○ Data not collected CURRENT NAME Clients] Last First Middle Suffix QUALITY OF CURRENT NAME ○ Full name reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client refused ○ Data not collected DATE OF BIRTH​ Clients] Age: Day Year QUALITY OF DATE OF ○ Full DOB reported ○ Client doesn’t know ○ Approximate or partial DOB reported ○ Client refused ○ Data not collected GENDER​ Clients] ○ Female ○ Client doesn’t know ○ Male ○ Client refused ○ Female (MTF or Male to Female) ○ Data not collected [All [All
VA-combined-Project-Intake-HMIS-2017-rev14Sept17.docx