Client refused ○ Yes ○ Data not collected ○ IF TO DOMESTIC VIOLENCE “YES” WHEN EXPERIENCE OCCURRED Within the past months One year ago or more ○ ○ Client doesn’t know ○ Three to six months ago (excluding six months exactly) ○ Client refused ○ Six months to one year ago (excluding one year exactly) Data not collected ○ ○ No Client doesn’t know ○ ○ Are you currently fleeing? Client refused ○ Yes ○ Data not collected ○ HOUSEHOLD INCOME AS A PERCENTAGE OF AMI of Household, not required for HUD VASH or GPD] Less than 30% ○ Greater than 50% ○ 30% to 50% ○ CONNECTION WITH SOAR of Households and Adults, not required for HUD VASH or GPD] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ LAST GRADE COMPLETED [Head of Household & Adults,not required for GPD] Less than 5 Grades 5-6 ○ ○ Grades 7-8 Grades 9-11 ○ ○ Grade 12 School does not have grade levels ○ ○ GED Some college ○ ○ Associate’s Degree Bachelor's degree ○ ○ Graduate Degree Vocational certification ○ ○ Client doesn't know ○ Data not collected Client refused ○ ○ EMPLOYMENT STATUS of Household, Adults, HUD-VASH OTH and SSVF] Employed No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○ If for employed Type of employment “Yes” – ○
○ Yes ○ Client refused ○ Data not collected IF “YES” TO DOMESTIC VIOLENCE WHEN EXPERIENCE OCCURRED ○ Within the past months ○ One year ago or more ○ Three to six months ago (excluding six months exactly) ○ Client doesn’t know ○ Client refused ○ Six months to one year ago (excluding one year exactly) ○ Data not collected Are you currently fleeing? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected HOUSEHOLD INCOME AS A PERCENTAGE OF AMI of Household, not required for HUD VASH or GPD] ○ Less than 30% ○ Greater than 50% ○ 30% to 50% CONNECTION WITH SOAR of Households and Adults, not required for HUD VASH or GPD] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected LAST GRADE COMPLETED of Household & Adults,not required for GPD] ○ Less than 5 ○ Grades 5-6 ○ Grades 7-8 ○ Grades 9-11 ○ Grade 12 ○ School does not have grade levels ○ GED ○ Some college ○ Associate’s Degree ○ Bachelor's degree ○ Graduate Degree ○ Vocational certification ○ Client doesn't know ○ Data not collected ○ Client refused EMPLOYMENT STATUS of Household, Adults, HUD-VASH OTH and SSVF] Employed ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected If “Yes” for employed – Type of employment ○ [Head
VA-combined-Project-Intake-HMIS-2017-rev07May2018.docx