Free Core HSRS Report - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-20031 (Rev. 08/2008)

CORE HUMAN SERVICES REPORTING SYSTEM
CLIENT REGISTRATION - Screen 11
Episode Key 1 Worker ID

STATE OF WISCONSIN SOS Desk (608) 266-9198 Completion of this form meets the requirements of the State / County contract specified under the Wisconsin Statutes. S. 46.031(2g)

MODULE TYPE 1

Enter either the client ID (field 2b) or full name, birthdate and sex (fields 3-5).
2b Client ID

2a Social Security Number

3a Last Name

3b First Name

3c Middle Name

3d Suffix

4 Birthdate (mm/dd/yyyy)

5 Sex F M

6a Hispanic / Latino Yes No

6b Race (Circle up to 5) A = Asian B = Black or African American P = Native Hawaiian or Pacific Islander I = American Indian or Alaskan Native

7 Client Characteristics W = White

OPTIONAL DATA - Screen 11
8a Street Address 8b City 8c State 8d ZIP Code 8e County 8f Telephone Number

(
9 Start Date 10 Case Review Date 11 Diagnosis 12 Closing Date 13 Closing Reason 14 Family ID 15 Local Data

)

CLIENT SERVICE - Screen 14
Prog. No. (U) 16 SPC Cluster or Category 17 Target Group 18 Days of Care 19 Other Units 20 Delivery Date (mm) (yyyy) 21 SPC Start Date 22 SPC End Date 23 Provider Number 24 SPC Review Date (mm) (yyyy)

Shaded areas optional.