Participating Agency Information [Agency Name] [Address] [City, state zip] [Phone] Universal Month / Intake Day / Form Year HMIS Client ID# Housing Move-in Date Client Data Not refused Collected Client does to (first, middle, last name, suffix (e.g., Jr, Sr, III)) Name of Head of Household not know provide  First Name Middle Name   Last Name Suffix    Name Data Full     Name Reported Partial, Street Name or Code name Quality:  SSN    SSN Data Full    SSN Reported Approximate or partial SSN reported Quality  Veteran Status   (Collected at Yes No  Record Creation) Child of HOH Use a separate HH Member SELF Relationship  Spouse or Partner Supplemental page for each HH (to HoH)  member Non-Relation IL- 510 (Chicago) IL- 502 (Lake County)   Client IL-511 (Suburban Cook Co.) IL- 514 (Dupage County)   Location IL- 506 (Will County) IN- 502 (IN- Lake Co)   Date of Birth    Trans Female: (MTF or Male to Female) Trans Male: (FTM or Male Gender    Female to Male) Female Gender (i.e., not exclusively male or female) Ethnicity    Non-Hispanic/Latino Hispanic/Latino Native Hawaiian or American Indian or Alaskan Black/African American Other Pacific Primary Race Native    Islander Asian Other Native Hawaiian or Secondary American Indian or Alaskan American Other Pacific Native  Race (Leave NA NA Islander White Blank if None) Asian Other
Universal Intake Form Participating Agency Information [Agency Name] [Address] [City, state zip] [Phone] Month / Day / Year HMIS Client ID# Housing Move-in Date Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client does not know Client refused to provide Data Not Collected First Name Middle Name    Last Name Suffix   Name Data Quality: Full Name Reported  Partial, Street Name or Code name      SSN    SSN Data Quality Full SSN Reported  Approximate or partial SSN reported    Veteran Status (Collected at Record Creation) Yes No    Relationship (to HoH) SELF  Child of HOH Spouse or Partner Non-Relation Use a separate HH Member Supplemental page for each HH member  Client Location  IL- 510 (Chicago)  IL- 502 (Lake County)  IL-511 (Suburban Cook Co.)  IL- 514 (Dupage County)  IL- 506 (Will County)  IN- 502 (IN- Lake Co) Date of Birth    Gender Male Female Trans Female: (MTF or Male to Female) Trans Male: (FTM or Female to Male) Gender (i.e., not exclusively male or female)    Ethnicity Non-Hispanic/Latino Hispanic/Latino    Primary Race American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Other Pacific Islander Other    Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian American White Native Hawaiian or Other Pacific Islander Other NA NA 
Universal_Intake_Form_-_9-2017.docx