CLARITY HMIS: VA SERVICES STATUS 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. CLIENT NAME OR IDENTIFIER:__________________________________________________ PROJECT STATUS DATE​ Clients] Month Day Year CLIENT LOCATION [only if multiple CoC’s] ______________________ CONNECTION WITH SOAR of Households and Adults, SSVF only] SOAR No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IN PERMANENT HOUSING Housing Projects, for Heads of Households] No Yes ○ ○ IF TO PERMANENT HOUSING “YES” Housing Move-in Date ____/____/__________ DISABLING CONDITION Clients] No ○ ○ Client doesn’t know Client refused ○ Yes ○ Data not collected ○ PHYSICAL DISABILITY required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO PHYSICAL DISABILITY SPECIFY “YES” – No Client know Expected to be of long-continued and indefinite duration and ○ ○ Client refused substantially impairs ability to live independently? ○ Yes ○ Data not collected ○ DEVELOPMENTAL DISABILITY required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DEVELOPMENTAL DISABILITY SPECIFY “YES” –
CLARITY HMIS: VA SERVICES STATUS 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. CLIENT NAME OR IDENTIFIER:__________________________________________________ PROJECT STATUS DATE​ Clients] Month Day Year CLIENT LOCATION [only if multiple CoC’s] ______________________ CONNECTION WITH SOAR of Households and Adults, SSVF only] SOAR ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IN PERMANENT HOUSING Housing Projects, for Heads of Households] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING Housing Move-in Date ____/____/__________ DISABLING CONDITION Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected PHYSICAL DISABILITY required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO PHYSICAL DISABILITY – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected DEVELOPMENTAL DISABILITY required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY
VA-Combined-Project-Status-HMIS-2017.docx