6 - 10 ○ 11 20 ○ – 20 or More ○ Approximate Number of Spent in an Inpatient Medical Facility 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 ○ PRIMARY LANGUAGE Clients, optional] English Mandarin ○ ○ Spanish Tagalog ○ ○ ○ Vietnamese ○ Unknown ○ Signature of applicant stating all information is true and correct Date
○ 6 - 10 ○ 11 – 20 ○ 20 or More Approximate Number of Spent in an Inpatient Medical Facility 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 PRIMARY LANGUAGE Clients, optional] ○ English ○ Mandarin ○ Spanish ○ Tagalog ○ Vietnamese ○ ○ Unknown Signature of applicant stating all information is true and correct Date
VA-combined-Project-Intake-HMIS-2017-rev14Sept17.docx