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Provider & Quarterly Reporting Information
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Quarterly Report Survey Start Time
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Today's Date
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Program (Find this information in the e-mail sent to you)
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HACLA
LACDA
Grant/Contract # (Find this information in the e-mail sent to you)
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CA0324
CA0405
CA1337
CA0393
CA0365 (DMH 1)
CA1046 (DMH 8)
CA1158 (DMH 9)
CA1688 (DMH 13)
Quarter Period (Find this information in the e-mail sent to you)
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1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Provider/Agency Name
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Provider Number (ICMS Providers input '0000')
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Case Manager Name
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Case Manager Phone #
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Case Manager E-mail
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Client Information
Client First Name
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Client Last Name
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Client IBHIS #
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Did client continue receiving services with your agency throughout the entire quarter?
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No
Yes
If client did not receive services with your agency throughout the entire quarter, please select a reason:
Client dropped out / non-compliant
Client elected to close case
Client graduated / successfully completed the program
Client transferred to another agency
Other
Please explain why the client did not receive services with your agency throughout the entire quarter:
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What agency did the client transfer to?
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Date of Transfer
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Did client remain in their Continuum of Care (CoC) housing unit during the entire quarter?
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No
Yes
Did client income information change in the previous 3 months?
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No
Yes
Unknown
If you selected Unknown above, please explain:
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Cash-Income Sources This Quarter
Cash Benefits this quarter: Check all that apply
Please provide specific monthly income amounts for each source selected above. For Example: GA $228, SSI $104, Retirement $280
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Non-Cash Benefits This Quarter
Non-Cash Benefits this quarter: Check all that apply
Comments / Concerns:
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Provider & Quarterly Reporting Information