Free Human Services Reporting System Core - Wisconsin

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

CORE HUMAN SERVICES REPORTING SYSTEM MULTIPLE CLIENTS
MODULE TYPE I
2a Social Security Number

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

CLIENT REGISTRATION - Screen 11
Episode Key 1 Worker ID

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

3a Last Name

3b First Name

3c Middle Name

3d Suffix

4 Birthdate (mm/dd/yyyy) ____ / ____ / _______

5 Sex F M

6a Hispanic / Latino Y = Yes N = No

6b Race (Circle up to 5) A = Asian B = Black or African American I = American Indian or Alaska Native

7 Client Characteristics W = White P = Native Hawaiian or Pacific Islander

OPTIONAL DATA - Screen 11
8a Street Address 8b City 8c State 8d ZIP Code 8e County 8f Telephone ( 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 (mm) (dd) (yyyy) 22 SPC End Date (mm) (dd) (yyyy) 23 Provider Number 24 SPC Review Date (mm) (yyyy)

Shaded areas optional.

OVER

FAMILY MEMBER / RELEVANT OTHER - CLIENT REGISTRATION - Screen 11
Episode Key 3a Last Name 1 Worker ID 3b First Name 2a Social Security Number 3c Middle Name 2b Client ID 3d Suffix 4 Birthdate (mm/dd/yyyy) ____ / ____ / _______ 6a Hispanic / Latino Y = Yes N = No 6b Race (Circle up to 5) A = Asian B = Black or African American I = American Indian or Alaska Native 7 Client Characteristics W = White P = Native Hawaiian or Pacific Islander 5 Sex F M

OPTIONAL DATA - Screen 11
8a Street Address 9 Start Date 10 Case Review Date 11 Diagnosis 8b City 12 Closing Date 8c State 13 Closing Reason 8d ZIP Code 14 Family ID 8e County 15 Local Data 8f Telephone ( )

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

FAMILY MEMBER / RELEVANT OTHER - CLIENT REGISTRATION - Screen 11
Episode Key 3a Last Name 1 Worker ID 3b First Name 2a Social Security Number 3c MIddle Name 2b Client ID 3d Suffix 4 Birthdate (mm/dd/yyyy) ____ / ____ / _______ 6a Hispanic / Latino Y = Yes N = No 6b Race (Circle up to 5) A = Asian B = Black or African American I = American Indian or Alaska Native 7 Client Characteristics W = White P = Native Hawaiian or Pacific Islander 5 Sex F M

OPTIONAL DATA - Screen 11
8a Street Address 9 Start Date 10 Case Review Date 11 Diagnosis 8b City 12 Closing Date 8c State 13 Closing Reason 8d ZIP Code 14 Family ID 8e County 15 Local Data 8f Telephone ( )

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