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HMIS
Easy Entry Form
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User:  Nick Mondau
Agency:  CTED Housing Division
Program:  CTED Training Program
Access Level:  System User
Sharing Mode:   OFF / Turn On
  
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 Household Member #1 (Head of Household)
First name:
 Don't know Refused		 Middle name:
 Don't know Refused		 Last name:
 Don't know Refused		 Suffix (Jr., II, etc.):
 Don't know Refused
 Birth Month: 
 Don't know Refused		  Birth Day: 
 Don't know Refused		  Birth Year: 
 Don't know Refused		 Gender:
Male Female
Refused
SSN: - -
 Don't know Refused Don't have
Race/Ethnicity (select one or more)
American Indian/Alaskan Native Asian
Black/African-American Hispanic/Latino
Native Hawaiian/Other-Pacific Islander White
Don't know Refused 
 Ever served on active duty in US military?
No Yes
Don't know Refused 


Household Intake/Housing History  
Residence prior to program entry Zip code of last permanent residence
 Don't know Refused

Services Provided  
Services date begin:  Pick a date  Services date end:  Pick a date 
Services Provided  Emergency Shelter Case Management

Exit Information  
Residence of household after exit
Notes
 

1000 additional characters allowed.