Form 1 RHY-HMIS Data Elements

RHY Program Specific Data Element - Collection Requirements
Within HMIS, different funding sources and projects require collection of different program specific
information. The Program Specific Data Elements are elements that are designed and managed by at least
one of the HMIS federal partner programs. Some of program specific data elements are collected across
most federal partner programs; these are called “Common” Program Specific Data Elements. The table
below shows all Program Specific Data Elements in which at least one RHY program component is required
to collect information.
Number
4.02
4.03
4.04
4.05
4.06
4.07
4.09
4.10
4.12
4.13
R1
R2
R3
R4
R5
R6
R7
R8
R9
R10
R11
R12
R13
R14
R15
R16
R17
R18
R19
R20

Element
Income and Sources
Non-Cash Benefits
Health Insurance
Physical Disability
Developmental Disability
Chronic Health Condition
Mental Health Problem
Substance Abuse
Current Living Situation
Date of Engagement
Referral Source
RHY: BCP Status
Sexual Orientation
Last Grade Completed
School Status
Employment Status
General Health Status
Dental Health Status
Mental Health Status
Pregnancy Status
Formerly a Ward of Child Welfare/Foster Care
Agency
Formerly a Ward of Juvenile Justice System
Family Critical Issues
RHY Service Connections
Commercial Sexual Exploitation/Sex Trafficking
Labor Trafficking
Project Completion Status
Counseling
Safe and Appropriate Exit
Aftercare

X = data collection is required

BCP es

BCP p

MGH

x
x
x
x
x
x
x
x

x
x
x
x
x
x
x

x
x
x
x
x
x
x

x
x
x
x
x
x
x
x
x
x
x

x
x
x
x
x
x
x
x
x
x
x

x

x
x
x
x
x
x
x
x
x

x
x
x
x
x

x
x
x
x
x
x
x
x
x

x
x

x
x
x
x
x
x
x
x
x

SOP

x
x
x
x
x
x
x
x

x

x

x
x

TLP

DEMO

x
x
x
x
x
x
x
x

x
x
x
x
x
x
x
x

x

x

x
x
x
x
x
x
x
x
x

x
x
x
x
x
x
x
x
x

x
x
x
x
x
x
x
x
x

x
x
x
x
x
x
x
x
x

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection
is to provide statistical information on youth served by your grant program. Public reporting burden for this collection of information is
estimated to average 89 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and
reviewing the collection of information. This is a mandatory collection of information as outlined in the RHY Act sections 312 and 322. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the
Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0XXX and the expiration date
is XX/XX/XXXX. If you have any comments on this collection of information, please contact TBD, Family and Youth Services Bureau, by email
at TBD.