Category

Information

Individual: Race/Ethnicity

Asian

African American

Hispanic

Middle Eastern

Native American

White

Unknown

Family: Position

Head

Spouse

Child

Other

Family: Marital Status

Married

Single

Divorced

Separated

Widowed

Unknown

Relationship to Program

Co-Habitant

Participant

New Intake

Renewed Intake

Relationship by Referral

Church Referral

Department of Health Services (DHS) Referral

Department of Social Services (DSS) Referral

Family Referral

Friend Referral

Non-Profit Referral

Read Next Step Pamphlet

Shelter Referral

Group: Disabled

No

Yes

Group: Employment

Day Labor

Full Time (FT)/No Benefits

Full Time (FT)/With Benefits

Part Time (PT) Irregular

Part Time (PT) Regular/No Benefits

Part Time (PT) Regular/With Benefits

Unemployed

Group: Ex-Offender

No

Yes

Group: Faith Currently

Anglican

Baptist

Catholic

Episcopalian

Holiness

Lutheran

Methodist

None

Other Christian

Other Faith

Pentecostal

Presbyterian

Group: Housing

Friends/Family

Homeless/Halfway House

Homeless/Other

Homeless/Shelter

Homeless/Street

Homeless/Transitional Housing

Other/Not Homeless

Own Home

Rent/Lease Home

Group: Identification (ID)

Birth Certificate

Driver’s License

Food Stamp

Green Card

Non-Driver’s License

Passport

Social Security Card

Group: Progress Since Last Visit

Next Steps All Successful

No Next Steps Successful

Some Next Steps Successful

Group: Reason for Visit Today

Seeking Emergency Assistance

Seeking Employment Services

Seeking Social Services

Group: Weekly Work Hours

Work Hours/Week=0

Work Hours/Week=1-10

Work Hours/Week=11-20

Work Hours/Week=21-30

Work Hours/Week=31-40

Work Hours/Week=Over 40

Baptism: Faith Group

Anglican

Baptist

Catholic

Episcopalian

Holiness

Lutheran

Methodist

None

Other Christian

Other Faith

Pentecostal

Presbyterian

Termination: From Next Step Program

Completed

Death

Incarcerated

Moved

Unknown

Withdrew