Client refused ○ Yes ○ Data not collected ○ Theater of Operations: Iraq (Operation Iraqi Freedom) No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ Theater of Operations: Iraq (Operation New Dawn) No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ Theater of Operations: operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ Branch of the Military Army Coast Guard ○ ○ Air Force Client know ○ ○ Navy Client refused ○ ○ Marines Data not collected ○ ○ Discharge Status Honorable Dishonorable ○ ○ General honorable conditions Uncharacterized ○ ○ Client doesn’t know ○ Other than honorable conditions (OTH) ○ Client refused ○ Bad Conduct Data not collected ○ ○ RELATIONSHIP TO HEAD OF HOUSEHOLD Client Households] Self ○ Head of household - other relation to ○ Head of household’s ○ Head of household’s spouse or partner Other: member ○ ○ CLIENT LOCATION [only if multiple CoC’s] ______________________ ZIP CODE OF LAST PERMANENT ADDRESS Clients] WHEN CLIENT WAS ENGAGED Outreach Only] Date of Engagement: ____/____/__________ IN PERMANENT HOUSING [Permanent Housing Projects, for Heads of Households] No Yes ○ ○ IF TO PERMANENT HOUSING “YES”
○ Yes ○ Client refused ○ Data not collected Theater of Operations: Iraq (Operation Iraqi Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Iraq (Operation New Dawn) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Branch of the Military ○ Army ○ Coast Guard ○ Air Force ○ Client know ○ Navy ○ Client refused ○ Marines ○ Data not collected Discharge Status ○ Honorable ○ Dishonorable ○ General honorable conditions ○ Uncharacterized ○ Other than honorable conditions (OTH) ○ Client doesn’t know ○ Client refused ○ Bad Conduct ○ Data not collected RELATIONSHIP TO HEAD OF HOUSEHOLD Client Households] ○ Self ○ Head of household - other relation to ○ Head of household’s ○ Head of household’s spouse or partner ○ Other: member CLIENT LOCATION [only if multiple CoC’s] ______________________ ZIP CODE OF LAST PERMANENT ADDRESS Clients] WHEN CLIENT WAS ENGAGED Outreach Only] Date of Engagement: ____/____/__________ IN PERMANENT HOUSING [Permanent Housing Projects, for Heads of Households] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING
CoC-Project-Intake-HMIS-2017-rev14Sept17.docx