2014 MINIMUM CoC DATA REQUIREMENTS (On client Entry)
Please complete one sheet for each person served, whether they are an individual or a family member
Project Entry Date: _____/_____/_______ Project Name:__________________________________________
ServicePointClient ID ________________________
Is Client the Head of Household?  Yes  No
If Client is Not Head of Household, Head of Household Name: _____________________________________________
First Name:
Name Type:
MI:
Last Name: _______________________________ Suffix: ___________
 Full Name Reported
 Partial, Street Name, or Code Name Reported
 Client Doesn’t Know
 Client Refused
 Data Not Collected
SSN: _________ – ________ – _____________
SSN Type:
 Full
 Approximate/Partial
 Client Doesn’t Know
 Client Refused
 Data Not Collected
U.S. Military Veteran? (clients 18 and older): Yes No Client Doesn’t Know Client Refused Data Not Collected
DOB(mm/dd/yyyy) __
/
/
DOB Type:
Primary Race: American Indian or Alaska Native
 Full DOB
 Approximate or Partial DOB
 Client Doesn’t Know
 Client Refused
 Data Not Collected
 Asian
 Black/African American
  Native Hawaiian or Other Pacific Islander
 White
 Client Doesn’t know
 Client Refused
 Data Not Collected
 American Indian or Alaska Native
 Asian
 Black/African American
  Native Hawaiian or Other Pacific Islander
 White
 Client Doesn’t know
 Client Refused
 Data Not Collected
Secondary
Race:
Ethnicity:
 Hispanic/Latino
 Non-Hispanic /Latino)
 Client Doesn’t Know
 Client Refused
 Data Not Collected
Gender:
 Female
 Male
 Transgender Male to Female
 Transgender Female to Male
 Other - If other gender, specify ________________________________
 Client Doesn’t Know
 Client Refused
 Data Not Collected
Page 1 of 4
2014 MINIMUM CoC DATA REQUIREMENTS (On client Entry)
Residence Prior to Program Entry:
(choose one)
 Emergency Shelter
 Foster Care Home or Foster Care Group Home
 Hospital or other Residential Non-Psychiatric Medical Facility
 Hotel or Motel Paid for without an 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
 Place Not Meant for Habitation
 Psychiatric Hospital or Other Psychiatric Facility
 Rental by Client, No Ongoing Housing Subsidy
 Rental by Client with VASH Subsidy
 Rental by Client with GPD TIP Subsidy
 Rental by Client with Other Ongoing Housing Subsidy (Non-VASH)
 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 (includes homeless youth)
 Other (specify)_________________________________________
 Client Doesn’t Know
 Client Refused
 Data Not Collected
 1 day or less

 2 days to 1 week
  More than 1 week but less than 1 month
  1 to 3 months
  More than 3 months but less than 1 year
Length of stay at location selected above:




 1 year or longer
 Client Doesn’t Know
 Client Refused
 Data Not Collected
Relationship to Head of Household:  Self
 Head of Household’s Child
 Head of Household’s Spouse or Partner
 Other Relation to Head of Household
 Other Non-Related Member
 Data Not Collected
Continuously Homeless for at Least One Year: Yes No 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 
 Client Doesn’t Know
 Client Refused
 Data Not Collected

If 4 or more, Total Number of Months Homeless in the Past Three Years: ___________ (record number up to 12 months)
 More than 12 months
 Client Doesn’t Know
 Client Refused
 Data Not Collected
Total Number of Months Continuously Homeless Immediately Prior to Project Entry: ___________________
Length of Time Homeless - Status Documented?  Yes
 No
Page 2 of 4
2014 MINIMUM CoC DATA REQUIREMENTS (On client Entry)
Receiving Income from any source? Yes No Client Doesn’t Know Client Refused Data Not Collected
Receiving
Income
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Source of Income (Check all that apply)
Income
Amount
Alimony or Other Spousal Support
$
Child Support
$
Earned Income
$
General Assistance
$
Pension or Retirement Income from Another Job
$
Private Disability Insurance
$
Retirement Income From Social Security
$
Social Security Disability Income (SSDI)
$
Supplemental Security Income (SSI)
$
Temporary Assistance for Needy Families (TANF)
$
Unemployment Insurance
$
VA Non-Service Connected Disability Pension
$
VA Service Connected Disability Compensation
$
Worker’s Compensation
$
Other – Specify Source _____________________
$
Receiving Non-Cash Benefit from any source? Yes No Client Doesn’t Know Client Refused Data Not Collected
Receiving Benefit Source of Non-Cash Benefit (Check all that apply)
Benefit Amount
(when applicable)
$
Yes No
Supplemental Nutrition Assistance Program (SNAP – Food Stamps)
Yes No
Special Supplemental Nutrition Program for Women, Infants and Children (WIC) $
Yes No
TANF Child Care services
$
Yes No
TANF transportation services
$
Yes No
Other TANF-funded services
$
Yes No
Section 8, public housing, or other ongoing rental assistance
$
Yes No
Temporary Rental Assistance
$
Yes No
Other Source – Specify Source _____________________________________
$
Is Client Covered by Health Insurance?
Covered
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No Client Doesn’t Know Client Refused Data Not Collected
Health Insurance Type (Check all that apply)
MEDICAID or MEDI-CAL
MEDICARE
State Children’s Health Insurance Program
Veteran’s Administration (VA) Medical Services
Employer-Provided Health Insurance
Health Insurance obtained through COBRA
Private Pay Health Insurance
State Health Insurance for Adults
Does the client have a disabling condition? Yes No Client Doesn’t Know Client Refused Data Not Collected
Page 3 of 4
2014 MINIMUM CoC DATA REQUIREMENTS (On client Entry)
Disability Type
Alcohol Abuse
Yes No
Client Doesn’t Know
Client Refused
Drug Abuse
Both Alcohol and
Drug Abuse
Chronic Health
Condition
Yes No
Client Doesn’t Know
Client Refused
Developmental
Yes No
Client Doesn’t Know
Client Refused
HIV/AIDS
Currently Receiving
Services or Treatment?

Yes
No
Yes
No
Client Doesn’t Know
Client Refused
Yes
No
Client Doesn’t Know
Client Refused
Yes
No
Client Doesn’t Know
Client Refused

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No
 Yes
Yes No
No Client Doesn’t Know

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No
Client Refused

Yes
No

Yes
No
Yes No
Client Doesn’t Know
Client Refused
Mental Health Problem
Physical
Documentation of
the
disability and
severity on file?

Yes
No
Yes No
Client Doesn’t Know
Client Refused
Yes No
Client Doesn’t Know
Client Refused
Expected to be of long-continued
and indefinite duration and
substantially impairs ability to live
independently

Yes
No
Yes No
Client Doesn’t Know
Client Refused
Yes No
Client Doesn’t Know
Client Refused
Going
to be
longterm?

Yes
No

Yes
No
Yes
No
Client Doesn’t Know
Client Refused
Yes
No
Client Doesn’t Know
Client Refused
Yes
No
Client Doesn’t Know
Client Refused
Yes
No
Client Doesn’t Know
Client Refused
Has the client ever been a victim of domestic violence?
 Yes  No  Client Doesn’t Know  Client Refused  Data Not Collected
If yes, how long ago?  Within the past three months
 Three to six months ago
 From six to twelve months ago
 More than a year ago
 Client Doesn't know
 Client Refused
In permanent housing? (Rapid Rehousing Only)  Yes  No
If yes, date of move-in: _______/________/_____________
Page 4 of 4