HUD CoC and ESG Entry Intake Form
HUD CoC and ESG Entry Intake Form DATE Fill out a separate form for each household member at the time of program entry. Clip all households member forms together. Name First M Social Security Number Last Name Data Quality Full name reported Partial or street name reported Client doesn’t know Client refused Data not collected U.S. Military Veteran? Yes (HUD) No (HUD) Client doesn’t know Client refused Data not collected SSN Data Quality Date of Birth* Primary Race* Secondary Race - If Applicable American Indian or Alaska Native (HUD) Date of Birth type* Full DOB reported (HUD) Approximate/partial DOB reported Client doesn’t know Client refused Data not collected American Indian or Alaska Native (HUD) Asian (HUD) Black or African American (HUD) Native Hawaiian or Other Pacific Islander White (HUD) Client doesn’t know Client refused Data not collected Asian (HUD) Black or African American (HUD) Native Hawaiian or Other Pacific Islander (HUD) White (HUD) Client doesn’t know Client refused Data not collected Ethnicity* Client Location* Non-Hispanic/Non-Latino Hispanic/Latino Client doesn’t know Client refused Data not collected Gender* Female Male Transgender male to female Transgender female to male Other: Specify Client doesn’t know Client refused Data not collected TX-503 Austin and Travis County TX-607 Surrounding counties If Yes for DV Victim/Survivor, when Experience Occurred: Domestic Violence Victim/Survivor? Yes No Client doesn’t know Within the past three months Six months to one year ago (excluding one Three to six months ago (excluding 6months exactly) Client refused Data not collected Health Insurance Full SSN reported Approximate or partial SSN reported Client doesn’t know Client refused Data not collected Client Enrolled in MAP ? Yes No Client doesn’t know Client refused Data not collected One year ago or more Client doesn’t know Client refused Data not collected HUD Verifications Covered by any of these Health Insurance types: Yes No MEDICAID MEDICARE State Children's Health Insurance Program Veterans Administration (VA) Medical Services Employer– Provided Health Insurance Health Insurance obtained through COBRA State Health insurance For Adults Private Pay Health Insurance Monthly Income/Benefits and sources* Receiving any of the following income sources: Earned income (i.e., employment income) Alimony or Other Spousal Support (HUD) Child Support (HUD) General Assistance (HUD) Other (HUD) Pension or retirement income from another job (HUD) Private Disability Insurance (HUD) Retirement Income From Social Security (HUD) SSDI (HUD) SSI (HUD) TANF (HUD) Unemployment Insurance (HUD) VA Service Connected Disability Compensation (HUD) VA Non-Service Connected Disability Pension (HUD) Worker's Compensation (HUD) ! Non-Cash Benefits* HUD Verifications Receiving any of the following Non-Cash benefit sources: Yes No Monthly Amount ! Start Date Supplemental Nutrition Assistance Program (Food Stamps) (HUD) Special Supplemental Nutrition Program for WIC (HUD) TANF Child Care Services (HUD) TANF Transportation Services (HUD) Other TANF-Funded Services (HUD) Section 8, Public Housing, or other ongoing rental assistance (HUD) Other Source (HUD) Temporary rental assistance (HUD) HUD Verifications Yes No Monthly amount start date ! Disabilities* Does client have any disabilities: HUD Verifications Yes No ! Expected to be of long duration? Alcohol Abuse (HUD) Drug Abuse (HUD) Both Alcohol and Drug Abuse (HUD) Chronic Health Condition (HUD) Developmental (HUD) HIV/AIDS (HUD) Mental Health Problem (HUD) Physical (HUD) Verification of information captured above: Covered by Health Insurance? Income from Any Source? Non-cash Benefit from any source? Does Client Have Disabling Condition? Yes No HUD CoC and ESG Entry Intake Form Chronic homeless status is determined by a client’s history of homelessness, disability status, and the length of time spent on the street, in an emergency shelter or a Safe Haven. The following questions help to identify Chronically homeless: Residence Prior to Project Entry Emergency shelter, including hotel or motel paid for with emergency shelter voucher Foster care home or foster care group home Hospital or other residential non-psychiatric medical facility Hotel or motel paid for without emergency shelter voucher Jail, prison or juvenile detention facility Long-term care facility or nursing home Owned by client, no ongoing housing subsidy Owned by client, with ongoing housing subsidy Permanent housing for formerly homeless persons (such as: CoC project; HUD legacy programs; or HOPWA PH) Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) Psychiatric hospital or other psychiatric facility Rental by client, with VASH subsidy Rental by client, with GPD TIP subsidy Rental by client, with other ongoing housing subsidy Residential project or halfway house with no homeless criteria Safe Haven Staying or living in a family member’s room, apartment or house Staying or living in a friend’s room, apartment or house Substance abuse treatment facility or detox center Transitional housing for homeless persons (including homeless youth) Other Client doesn’t know Client refused Data not collected Length of Stay in Previous Place One day or less Two days to one week More than one week, but less than one month One to three months More than three months, but less than one year One year or longer Is Client Chronically homeless? Yes (HUD) No HUD) Housing Status Category 1 – Homeless (HUD) Category 2 – At imminent risk of losing housing (HUD) Category 3 – Homeless only under other federal statutes Category 4 – Fleeing domestic violence At-risk of homelessness Stably housed Client doesn’t know Client refused Data not collected Names of individuals in household entering the program with you (or ServicePoint #): Relationship to Head of Household Self (head of household) Head of household’s child Head of household’s spouse or partner Head of household’s other relation member (other relation to head of household) Continuously Homeless for at Least One Year? Yes (HUD) No HUD) Client doesn’t know Client refused Data not collected Number of Times the Client has been Homeless in the Past Three Years 0 1 2 3 4 or more Other Client doesn’t know Client refused Data not collected (If 4 or more) Total Number of Months Homeless in the Past Three Years: 0 1 2 3 4 5 6 7 8 9 10 11 12 More than 12 Other Client doesn’t know Client refused Data not collected Total Number of Months Continuously Homeless Immediately Prior to Project Entry (partial months i.e. 1 day - 30 days = 1 month) Length of Time Homeless - Status Documented? Yes (HUD) No HUD) Remember, you are taking a persons story and converting it into HUD speak data elements plus ServicePoint database functionality, take your time with a client and record the data accurately.
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