Any Veteran in household served in Iraq or Afghanistan? Yes ○ ○ Female Veteran? Yes ○ ○ HP applicant points (integer) _____________ Grantee targeting threshold (integer) _______________ programs USE OF OTHER CRISIS SERVICES: [RRH/HP] of Household / Adults] Number of Visits to an Emergency Room in the Past Year? 0 Client doesn’t know ○ ○ 1 - 2 Client refused ○ ○ 3 - 5 Data not collected ○ ○ 6 - 10 ○ 11 20 ○ – 20 or More ○ Approximate Number of Nights in Jail/Prison in the Past Year? 0 Client doesn’t know ○ ○ 1 - 2 Client refused ○ ○ 3 - 5 Data not collected ○ ○
Any Veteran in household served in Iraq or Afghanistan? ○ Yes ○ Female Veteran? ○ Yes ○ HP applicant points (integer) _____________ Grantee targeting threshold (integer) _______________ USE OF OTHER CRISIS SERVICES: [RRH/HP] programs of Household / Adults] Number of Visits to an Emergency Room in the Past Year? ○ 0 ○ Client doesn’t know ○ 1 - 2 ○ Client refused ○ 3 - 5 ○ Data not collected ○ 6 - 10 ○ 11 – 20 ○ 20 or More Approximate Number of Nights in Jail/Prison in the Past Year? ○ 0 ○ Client doesn’t know ○ 1 - 2 ○ Client refused ○ 3 - 5 ○ Data not collected
VA-combined-Project-Intake-HMIS-2017-rev14Sept17.docx