> For the complete documentation index, see [llms.txt](https://dcyf.gitbook.io/cmshandbook/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://dcyf.gitbook.io/cmshandbook/appendix/appendix-b-sample-participant-profile.md).

# Appendix B: Sample Participant Profile

{% hint style="warning" icon="file-pdf" %}
Access a PDF version of this appendix in the CMS Resources page.
{% endhint %}

The sample intake form below shows the prompts and response options used in participant profiles in the CMS. Replicating these fields and values in your own intake forms will facilitate CMS data entry and support the collection of high-quality participant data.

***

### **ℹ️ Personal Information**

{% hint style="warning" %}
**if participant is a SFUSD student, enter information according to SFUSD records**
{% endhint %}

| First Name           | Last Name(s)         | Date of Birth        |
| -------------------- | -------------------- | -------------------- |
| \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ |

***

### ℹ️ **Housing Status**

 **Select one**

☐ Permanent/Stable Housing

☐ Homeless - Shelter/Emergency Housing

☐ Homeless - Motel/Hotel

☐ Homeless - Staying with Friends/ Family Doubled-up

☐ Homeless - Transitional/Supportive Housing

☐ Homeless - Unsheltered

☐ Unknown

***

### ℹ️ **Home Address**

| Street Address       | Apt./Unit            |
| -------------------- | -------------------- |
| \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ |

| City                 | State                | Zip                  |
| -------------------- | -------------------- | -------------------- |
| \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_ |

***

### ℹ️ **Home Language**

{% hint style="info" %}
**Select one**
{% endhint %}

☐ English

☐ Spanish

☐ Cantonese

☐ Japanese

☐ Arabic

☐ Khmer/Cambodian

☐ Korean

☐ Laotian

☐ Mandarin

☐ American Sign Language

☐ Samoan

☐ Tagalog

☐ Toishanese

☐ Vietnamese

☐ Russian

☐ Unspecified

☐ Other, specify language: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***

### ℹ️ **Race/Ethnicity**

{% hint style="info" %}
**Select one**
{% endhint %}

☐ African American

☐ Other Black (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Hispanic/Latino - Mexican/Mexican American

☐ Hispanic/Latino - Central American

☐ Hispanic/Latino - South American

☐ Hispanic/Latino - Caribbean

☐ Hispanic/Latino - Other (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Asian - Chinese

☐ Asian - Filipino

☐ Asian - Indian

☐ Asian - Japanese

☐ Asian - Khmer/Cambodian

☐ Asian - Korean

☐ Asian - Laotian

☐ Asian - Thai

☐ Asian - Vietnamese

☐ Asian - Other (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Middle Eastern - Arab

☐ Middle Eastern - Iranian

☐ Middle Eastern - Other (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Pacific Islander - Guamanian

☐ Pacific Islander - Hawaiian

☐ Pacific Islander - Tongan

☐ Pacific Islander - Samoan

☐ Pacific Islander - Other (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ White

☐ Multiracial/ Multiethnic

☐ Other (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Native American

☐ Native Alaskan

☐ Declined to state

### ℹ️ **Gender/Gender Identity (select one)**

{% hint style="warning" %}
**Participants Under 18 Years Old (select one)**
{% endhint %}

**What is your gender?**

☐ Female

☐ Male

☐ Transgender

☐ Declined/Not Stated

***

{% hint style="warning" %}
**Participants 18 Years Old or Over (select one)**
{% endhint %}

**What is your gender?**

☐ Female

☐ Male

☐ Trans Male

☐ Trans Female

☐ Genderqueer/Gender Non-Binary

☐ Not listed (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Declined/Not Stated

***

### ℹ️ **Sexual Orientation/Sexual Identity (select one)**

{% hint style="warning" %}
**Participants Under 18 Years Old**
{% endhint %}

#### **Do you identify as gay, lesbian, or bisexual? (select one)**

☐ Y

☐ N

☐ Unspecified

{% hint style="warning" %}
**Participants 18 Years Old or Over**
{% endhint %}

#### **Sexual Orientation/Sexual Identity (select one)**

☐ Bisexual

☐ Gay/Lesbian/Same-Gender Loving

☐ Questioning/Unsure

☐ Straight/Heterosexual

☐ Declined/Not Stated

☐ Not listed (specify below) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***

### ℹ️ **Educational Attainment (select one)**

☐ Not yet attending K-12

☐ Completed high school diploma or GED

☐ Dropped out of K-12 before diploma

☐ GED Program

☐ Post Secondary

☐ Currently attending K-12 (if selected, complete the section below)

☐ K-12 Grade Level: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Does not attend school

☐ Declined/Not Stated

***

#### ℹ️ **If participant currently attends K-12, select one of the options below**

☐ Enrolled in San Francisco Unified School District (SFUSD)

☐ Specify School Attending: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

☐ Attends School Outside SF

☐ Homeschooled

☐ Parochial/Private

☐ City Arts and Tech HS Charter

☐ Creative Arts K-8 Charter

☐ Early Morning Study Program HS (County)

☐ Edison K-8 Charter Academy

☐ Five Keys Adult HS Charter American Sign Language

☐ Log Cabin Ranch HS Court School (County)

☐ Gateway HS Charter

☐ Gateway MS Charter

☐ Hilltop HS (County)

☐ KIPP San Francisco Bay MS Academy Charter

☐ KIPP Bayview Academy MS Charter

☐ KIPP SF College Preparatory Charter

☐ Life Learning HS Academy Charter Leadership HS Charter

☐ Metropolitan Arts & Technology HS Charter

☐ Mission Preparatory K-8 School Charter

☐ SF CFC Center Secondary HS (County)

☐ SF Civic Center Secondary MS (County)

☐ SF Court Woodside Learning Ctr (County)