HMIS Child Status & Annual Assessment Form - CoC Programs
Annual Assessments are REQUIRED for Adults and Children.
Complete a separate form for each Child. [All Clients = Adults & Children]
Important: Annual Assessments must be recorded no more than 30 days before or after the
anniversary of the client’s Project Entry Date, regardless of the most recent ‘update’ or
‘annual assessment’, if any. Information must be accurate as of the assessment date.
*Status Assessments are not required and can be completed at multiple points during project
enrollment to track key events (e.g. a change in income and sources)*
Last Name:
Middle Name:
First Name:
Social Security #
Date of Birth
Project Name:
Project Assessment Date:
Head of Household:
Staff Completing Form:
PHYSICAL DISABILITY [All Clients]
No
Client doesn’t know
Yes
Client refused
IF “YES” TO PHYSICAL DISABILITY – SPECIFY
Receiving services for physical disability
Is the physical disability expected to be of long-continued
and indefinite duration and substantially impairs ability to
live independently.
Documentation of the disability and severity on file
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Yes
Client refused
No
Yes
No
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Client refused
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Yes
Client refused
No
Yes
DEVELOPMENTAL DISABILITY [All Clients]
No
Client doesn’t know
Yes
Client refused
IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY
Receiving services for developmental disability
Is the developmental disability expected to substantially
impair ability to live independently?
Documentation of the disability and severity on file
CHRONIC HEALTH CONDITION [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY
Currently receiving services/treatment for this condition
Is the condition expected to be of long-continued and
indefinite duration and substantially impairs ability to live
independently.
Documentation of the disability and severity on file
CHILD HMIS Assessment Form - CoC Programs
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HMIS Child Status & Annual Assessment Form - CoC Programs
HIV-AIDS [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO HIV-AIDS – SPECIFY
Currently receiving services/treatment for this condition
Is the condition expected to substantially impair ability to
live independently?
Documentation of the disability and severity on file
No
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Client refused
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Yes
Client refused
No
Yes
MENTAL HEALTH PROBLEMS [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO MENTAL HEALTH PROBLEMS – SPECIFY
Currently receiving services/treatment for this condition
Is the condition expected to be of long-continued and
indefinite duration and substantially impairs ability to live
independently.
Documentation of the disability and severity on file
SUBSTANCE ABUSE PROBLEMS [All Clients]
No
Both alcohol and drug abuse
Alcohol abuse
Client doesn’t know
Drug abuse
Client refused
IF “YES” TO ALCOHOL ABUSE, DRUG ABUSE OR BOTH – SPECIFY
No
Currently receiving services/treatment for this condition
Yes
Is the condition expected to be of long-continued and
No
indefinite duration and substantially impairs ability to live
Yes
independently.
Documentation of the disability and severity on file
No
Client doesn’t know
Client refused
Client doesn’t know
Client refused
Yes
COVERED BY HEALTH INSURANCE [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO HEALTH INSURANCE - HEALTH INSURANCE COVERAGE DETAILS
MEDICAID (aka Medi-Cal)
Employer Provided
MEDICARE
Obtained through COBRA
SCHIP (Do Not Use)
Private Pay Health Insurance
VA Medical
State Health Insurance for Adults (Do Not Use)
CHILD HMIS Assessment Form - CoC Programs
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HMIS Child Status & Annual Assessment Form - CoC Programs
EMPLOYMENT
[All Clients, For Age 16 & Over]
Employed: ☐Yes ☐No ☐Don’t know ☐Refused (If yes, Hours worked Last Week: _____)
Employment Tenure/Stability: ☐Permanent ☐Temp ☐Seasonal ☐Don’t know ☐Refused
If Not Employed, Seeking Employment: ☐Yes ☐No ☐Don’t know ☐Refused
EDUCATION
[All Clients, For Age 5 & over]
Currently Enrolled in School: ☐Yes ☐No ☐Don’t know ☐Refused
If Enrolled:
Vocational Training or Apprenticeship: ☐Yes ☐No ☐Don’t know ☐Refused
Name of school enrolled: ___
__
Is child connected to the HUD homeless liaison: ☐Yes ☐No ☐Don’t know ☐Refused
Type of School: ☐Public
☐Parochial or other Private School
Highest Educational Level Completed:
☐
☐
☐
☐
☐
No School Completed
Nursery School to 4th Grade
5th or 6th Grade
7th or 8th Grade
9th Grade
☐
☐
☐
☐
☐
10th Grade
11th Grade
12th Grade (No Diploma)
GED
High School Diploma
☐ Postsecondary School
☐ Don’t know
☐ Refused
If Not Enrolled:
Date of the last enrollment: ___
__
Barrier to Enrolling Child in School:
☐
☐
☐
☐
☐
☐
None
Residency requirements
Availability of school records
Birth Certificate
Legal Guardianship required
Transportation
CHILD HMIS Assessment Form - CoC Programs
☐
☐
☐
☐
☐
☐
Lack of available preschool program
Immunization requirements
Physical examination records
Other
Don’t Know
Refused
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