Youth Gang Prevention Services by tgv36994

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									           MULTNOMAH COUNTY                                        Youth Gang Prevention Services
           DEPARTMENT OF SCHOOL AND COMMUNITY PARTNERSHIPS

                                                            Step 3 (Entry): Client Demographics                                           (page 1)



  Entry Data            (answer once per household)

  Include                            Yes
                                                                                                        Entry
                                              Provider (Don’t Change!)          Type Basic Entry/Exit   Date
  All Household Members?             No
                                                                                                                  Month        Day               Year



COMPLETE     FOR EACH HOUSEHOLD MEMBER:
   ServicePoint                                                                                                                                     Suffix
    Client ID       First Name                                                     M.I. Last Name                                                (Jr, II, etc)




Race*                                                  Primary Language*                                  Employment Status*
  American Indian or Alaska Native                       Albanian                                           Full-Time Employment
  Asian                                                  Amharic                                            Part-Time Employment
  Black or African-American                              Arabic                                             Job Training Program
  Native Hawaiian or Other Pacific Islander              Bosnian                                            Irregular Employment
  Other                                                  Cambodian                                          Not Employed -- Not Seeking
  Other Multi-Racial                                     Cantonese                                          Not Employed -- Seeking
  White                                                  Conjuval                                           Retired
                                                         English                                            Not Applicable (Not Employment Age)
                                                         Eritrean
Race - Additional                                        Farsi                                            Disabling Condition?*
  American Indian or Alaska Native                       French                                             Yes (specify Disability Type(s) below)
  Asian                                                  Hindi                                              No
  Black or African-American                              Hmong                                              Don’t Know
  Native Hawaiian or Other Pacific Islander              Laotian                                            Refused
  Other                                                  Mandarin Chinese                                                              Expected to Be of
  Other Multi-Racial                                     Mien                                             Disability Type(s)           Long Duration?
  White                                                  Portugese                                          Alcohol Abuse                  Yes    No
                                                         Romanian                                           Developmental                  Yes    No
                                                         Russian                                            Drug Abuse                     Yes    No
Race – Other (must specify)                              Samoan                                             Physical/Medical               Yes    No
                                                         Serbo-Croatian                                     Mental Illness                 Yes    No
                                                         Slovakian                                          Physical/Mobility Limits       Yes    No
                                                         Spanish                                            HIV/AIDS                       Yes    No
                                                         Swahili                                            Hearing Impaired               Yes    No
Ethnicity (Hispanic/Latino)*
                                                         Ukrainian                                          Vision Impaired                Yes    No
  Hispanic/Latino
                                                         Vietnamese                                         Dual Diagnosis                 Yes    No
  Non-Hispanic/Latino
                                                                                                            Other                          Yes    No
                                                       Primary Language – Other (must specify)
                                                                                                          If other, specify
Ethnicity (Non-Hispanic/Latino)
  African Immigrant
  Slavic/Eastern-European Immigrant
                                                       Highest Grade Completed*
                                                                                                          Domestic Violence Victim?*
                                                         Pre-Kindergarten
                                                                                                            Yes
                                                         Kindergarten
                                                                                                            No
                                                         1st
                                                         2nd
                                                                                                          Health Insurance*
                                                         3rd
                                                                                                            Private
                                                         4th
                                                                                                            Public (such as Oregon Health Plan)
                                                         5th
                                                                                                            None
                                                         6th
                                                                                                            Unknown
                                                         7th
                                                         8th
                                                                                                          Farmworker Status*
                                                         9th                                                Farmworker
                                                         10th                                               Migrant Farmworker
                                                         11th                                               Seasonal Farmworker
                                                         High School Diploma                                Unknown
                                                         GED                                                Not Applicable
                                                         Vocational School
                                                         1-2 Years College                                U.S. Military Veteran?*
                                                         3-4 Years College                                  Yes
                                                         Undergraduate Degree (or Equivalent)               No
                                                         Post-Bachelor's Degree                             Don’t Know
                                                         None                                               Refused
 *Required                                                                                                                     10/31/2006 v1.0

								
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