CLARITY HMIS: VA SERVICES INTAKE 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. PROJECT START DATE​ [All Clients] Day Year SOCIAL SECURITY NUMBER​ [All Clients] QUALITY OF SOCIAL SECURITY Client doesn’t know ○ Full SSN reported ○ Client refused ○ Approximate or partial SSN reported Data not collected ○ ○ N/A CURRENT NAME Clients] Last Middle Suffix QUALITY OF CURRENT NAME Full name reported Client doesn’t know ○ ○ Client refused ○ Partial, street name, or code name reported ○ Data not collected ○ DATE OF Clients] Age: Month Day Year QUALITY OF DATE OF BIRTH Full DOB reported Client doesn’t know ○ ○ Client refused ○ Approximate or partial DOB reported ○ Data not collected ○ GENDER​ Clients] Female Client doesn’t know ○ ○
CLARITY HMIS: VA SERVICES INTAKE 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. PROJECT START DATE​ Clients] Day Year SOCIAL SECURITY NUMBER​ Clients] QUALITY OF SOCIAL SECURITY ○ Full SSN reported ○ Client doesn’t know ○ Client refused ○ Approximate or partial SSN reported ○ Data not collected CURRENT NAME Clients] N/A Last Middle Suffix QUALITY OF CURRENT NAME ○ Full name reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client refused ○ Data not collected DATE OF Clients] Age: Month Day Year QUALITY OF DATE OF BIRTH ○ Full DOB reported ○ Client doesn’t know ○ Approximate or partial DOB reported ○ Client refused ○ Data not collected GENDER​ Clients] ○ Female ○ Client doesn’t know [All [All
VA-combined-Project-Intake-HMIS-2017-rev07May2018.docx