No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ CHRONIC HEALTH CONDITION required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO CHRONIC HEALTH CONDITION SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ HIV-AIDS required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO CHRONIC HEALTH CONDITION SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ MENTAL HEALTH PROBLEM required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO MENTAL HEALTH PROBLEMS SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ SUBSTANCE ABUSE PROBLEM required for SSVF] No Both alcohol & drug abuse ○ ○ Client doesn’t know ○ Alcohol abuse ○ Client refused ○ Drug Data not collected ○ ○ IF ABUSE” ABUSE” OR ALCOHOL AND DRUG ABUSE”– SPECIFY “ALCOHOL “DRUG “BOTH 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 ○ DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults, not required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DOMESTIC VIOLENCE “YES” WHEN EXPERIENCE OCCURRED
Expected to substantially impair ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected HIV-AIDS required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected MENTAL HEALTH PROBLEM required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO MENTAL HEALTH PROBLEMS – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected SUBSTANCE ABUSE PROBLEM required for SSVF] ○ No ○ Both alcohol & drug abuse ○ Alcohol abuse ○ Client doesn’t know ○ Client refused ○ Drug ○ Data not collected IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE”– 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 DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults, not required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DOMESTIC VIOLENCE WHEN EXPERIENCE OCCURRED
VA-Combined-Project-Status-HMIS-2017.docx