Exit DHS HS Supportive Housing Form for HMIS: SINGLES
Client Name ______HMIS ID: ______
First Middle Last Suffix
Data Collection Instructions:· Underlined terms have definitions provided at hmismn.org. Please print a copy to have available. / HMIS Tips:
· Use the General HMIS Instructions & your program’s (funder) User Guide for complete data entry instruction.
· EDA to Entry provider. No need to Backdate.
· Entry/Exit Tab: click pencil next to exit date. Continue to the Exit DHS HS Supportive Housing Assessment
Section 1: Exit Information (IN HMIS: use Entry/Exit Tab)
1. Exit Date: _____ /_____/ ______
2. Destination
£ Deceased£ Emergency shelter, including hotel or motel paid for with emergency shelter voucher
£ Foster care home or foster care group home
£ Hospital or other residential non-psychiatric medical facility
£ Hotel or motel paid for without emergency shelter voucher
£ Jail, prison or juvenile detention facility
£ Long-term care facility or nursing home
£ Moved from one HOPWA funded project to HOPWA PH
£ Moved from one HOPWA funded project to HOPWA TH
£ Owned by client, no ongoing housing subsidy
£ Owned by client, with ongoing housing subsidy / £ Permanent Housing (other than RRH) for formerly homeless persons
£ Rental by client, with RRH or equivalent subsidy
£ Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)
£ Psychiatric hospital or other psychiatric facility
£ Rental by client, no ongoing housing subsidy
£ Rental by client, with VASH housing subsidy
£ Rental by client, with GPD TIP housing subsidy
£ Rental by client, with other ongoing housing subsidy
£ Residential project or halfway house with no homeless criteria
£ Safe Haven / £ Staying or living with family, permanent tenure
£ Staying or living with family, temporary tenure (e.g., room, apartment or house)
£ Staying or living with friends, permanent tenure
£ Staying or living with friends, temporary tenure (e.g., room, apartment or house)
£ Substance abuse treatment facility or detox center
£ Transitional housing for homeless persons (including homeless youth)
£ Other (specify) ______
£ No exit interview completed
£ Client doesn't know
£ Client refused
£ Data not collected
Section 2: Health Insurance/Disability/Income/Non Cash Benefits Updates (In HMIS: Entry/Exit Tab)
Health Insurance Updates (In HMIS: Entry/Exit Tab Interims)
Data collection instructions:· Answer questions 1a, 1b, and 1c only if the client’s health insurance has started, ended, or changed source since entry or most recent update. / HMIS Tips:
· Enter new health insurance source using the “Add” button. Ensure that the HUD Verification step is complete. Select the edit pencil next to each health insurance source to add an end date. “Covered?” should remain “Yes” even after the health insurance ends.
1a. Is the client covered by health insurance? £ Yes £ No £ Client doesn’t know £ Client refused £ Data not collected
1b. New source of Health InsuranceStart Date (Month/Day/Year) / Start Date (Month/Day/Year)
MEDICAID (MA) / £ Yes / / / / Employer-Provided Health Insurance / £ Yes / / /
MEDICARE / £ Yes / / / / Health Insurance obtained through COBRA / £ Yes / / /
State Children’s Health Insurance Program / £ Yes / / / / Private Pay Health Insurance / £ Yes / / /
Veteran’s Administration (VA) Medical Services / £ Yes / / / / State Health Insurance for Adults / £ Yes / / /
Indian Health Services Program / £ Yes / / / / Other / £ Yes / / /
1c. Health insurance sources recorded previously that have since ended
Source 1 (enter name from lists above) / End date / Source 2 (enter name from lists above) / End date
______/ / / / ______/ / /
Disability Updates (In HMIS: Entry/Exit Tab Interims)
2a. Does the client have a disability of long duration? £ Yes £ No £ Client doesn’t know £ Client refused £ Data not collected
- Documentation is not required to answer “yes.” Clients can answer “yes” even if they have never been officially diagnosed with a disability (see definitions).
- Alcohol/drug abuse is considered a disability of long duration. Only record if the answer has changed since last update.
Data collection instructions:
· Use this table to record new disabilities not recorded previously.
· Start date: Use documentation date / HMIS Tips:
· Enter new disabilities using the Add button. Ensure that the HUD Verification step is complete. Select the edit pencil next to each disability type to add an end date. Disability Determination should be “Yes” if the client has the disability and should remain “Yes” even if the disability ends. (HUD)=HUD-approved source
2b. Newly-identified disabilities:
Disability Type / Disability Determination / Start Date / If Yes, Expected to be of long–continued and indefinite duration and substantially impairs ability to live independently? / Condition is long term w/ substantial impact?Mental Health Problem (HUD) / £ Yes £ No / £ DK £ R £ NC / Program Entry Date / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Physical (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Developmental (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Chronic Health Condition (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Alcohol Abuse (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Drug Abuse (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Both Alcohol and Drug Abuse (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
HIV/AIDS (HUD) / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Traumatic Brain Injury / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Hearing Impaired / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Vision Impaired / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
Other (Specify): ______/ £ Yes £ No / £ DK £ R £ NC / £ Yes £ No / £ DK £ R £ NC / £ Yes £ No
2c. Disabilities recorded previously that have since ENDED (not common):
Disability 1 (enter name from list above) / End date / Disability 2 (enter name from list above) / End date______/ ____ / ____ / ____ / ______/ ____ / ____ / ____
2d. Documentation updates: For new documentation obtained since program entry, note the determination of any previously-recorded disabilities: In HMIS, click the edit pencil to the left of the disability to update the “documentation” field for the disability as appropriate.
Documentation? (check "yes" if documented)Mental Health Problem recorded at entry? / £ Yes £ No
Physical Disability recorded at entry? / £ Yes £ No
Developmental Disability recorded at entry? / £ Yes £ No
Chronic Health Condition recorded at entry? / £ Yes £ No
Income Updates
HMIS Tips:· If income amount for a source has changed: record end date for the old amount one day before the start date of the new amount. Add new income record for that source using the “Add button.” Ensure that the HUD Verification step is complete.
· “Receiving income source” should remain “Yes” even after the income ends. (HUD)=HUD-approved income source
3a. New income sources/amounts: / Receiving income? / Start date / Monthly amount / Receiving income? / Start date / Monthly amount
Earned Income (HUD) / £Yes / / / / $ / VA Non-Service Connected Disability Pension (HUD) / £Yes / / / / $
Unemployment Insurance (HUD) / £Yes / / / / $ / Pension or retirement income from another job (HUD) / £Yes / / / / $
SSI (HUD) / £Yes / / / / $ / Child Support (HUD) / £Yes / / / / $
SSDI (HUD) / £Yes / / / / $ / Alimony or Other Spousal Support (HUD) / £Yes / / / / $
VA Service Connected Disability Compensation (HUD) / £Yes / / / / $ / Other (specify) (HUD) ______/ £Yes / / / / $
Private Disability Insurance (HUD) / £Yes / / / / $ / Contributions From Other People / £Yes / / / / $
Worker’s Compensation (HUD) / £Yes / / / / $ / Interest, Dividends, & Annuities / £Yes / / / / $
TANF (HUD) / £Yes / / / / $ / MSA/Minnesota Supplemental Aid / £Yes / / / / $
General Assistance (HUD) / £Yes / / / / $ / Student Grant/Scholarship / £Yes / / / / $
Retirement Income From Social Security (HUD) / £Yes / / / / $ / Tribal Funds / £Yes / / / / $
3b. Income sources recorded previously that have since ENDED: List below with end dates:
Income Source 1 (enter name from list above) / End date / Income Source 2 (enter name from list above) / End date / Income Source 3 (enter name from list above) / End date______/ / / / ______/ / / / ______/ / /
Non-Cash Benefit Updates
HMIS Tips:- Enter new benefit source using the “Add” button. Ensure that the HUD Verification step is complete. Select the edit pencil next to each benefit type source to add an end date. “Receiving benefit?” should remain “Yes” even if the benefit ends.
4a. New Non-Cash Benefits: / Receiving benefit? / Start date / Receiving benefit? / Start date
Supplemental Nutrition Assistance Program (Food Stamps) (HUD) / £Yes / / / / Other TANF-Funded Services (HUD) / £Yes / / /
Special Supplemental Nutrition Program (WIC) (HUD) / £Yes / / / / Other source (HUD) (specify)______/ £Yes / / /
TANF Child Care Services (HUD) / £Yes / / /
TANF Transportation services (HUD) / £Yes / / /
4b. Non-cash benefits recorded previously that have since ENDED: List below with end dates:
Benefit Source 1 (enter name from list above) / End date / Benefit Source 2 (enter name from list above) / End date / Benefit Source 3 (enter name from list above) / End date______/ / / / ______/ / / / ______/ / /
5a. Client Location (Head of Household-including Singles and Youth Heads of Household)
5b. Client’s Residence Updates:
Data Collection Instructions:· Update only if current residence status changed between the last update and program exit.
· All clients must have a residence record that covers the entire time they are enrolled in the program (NO Gaps or Overlaps)
· *If the client left current residence at exit, put an END DATE on the residence that matches the PROGRAM EXIT DATE. No need for new residence entry. / HMIS Tips:
· If a new residence is reported, end the previously-recorded HMIS residence record one day before the start date of the new residence.
o Add the new residence information (below) as an additional residence record. Click “Add” to add another record.
Current Residence Updates (enter # from list below) / Start Date / * End Date / Zip code / City / County
/ / / / /
1 / Site-based supportive housing / 5 / Hotel/motel without emergency shelter / 9 / Hospital / 13 / Jail, prison or juvenile facility
2 / Scattered-site supportive housing / 6 / Living with family / 10 / Psychiatric facility / 14 / Other
3 / Transitional housing for homeless / 7 / Living with friends / 11 / Substance abuse treatment center, including detox / 15 / Client does not know
4 / Emergency shelter / 8 / Foster care/group home / 12 / Place not meant for habitation / 16 / Client Refused
5c. For households in housing at exit, did the household stay in their apartment when they exited the program?
£ Left current residence at exit £ Left residence before exit £ Will remain in current residence at exit
5d. If applicable, reason for leaving housing:
£ / Successful completion of residential program / £ / On-site services do not meet needs / £ / Hospitalized or moved to residential treatment program / £ / Notice to vacate or non-renewal for lease violations, other than criminal or drug£ / Subsidy ended / £ / Location or neighborhood does not meet needs / £ / Incarcerated / £ / Notice to vacate or non-renewal for non-payment of rent
£ / Leaving damaged or substandard housing (including fire) / £ / Conflict with roommates or neighbors / £ / Legal eviction/UD for criminal/drug activity / £ / Left service area or residential program
£ / No longer meets eligibility requirements for residence / £ / Cannot afford rent / £ / Legal eviction/UD for lease violations, other than criminal or drug / £ / Death
£ / Non-compliance with residential program rules / £ / Leaving project-based voucher for tenant-based voucher / £ / Legal eviction/UD for non-payment of rent / £ / Unknown/disappeared
£ / Unit does not meet needs (including accessibility or size) / £ / Discharged or reached time limit / £ / Notice to vacate or non-renewal for criminal/drug activity / £ / Other (specify): ______
6a. Housing Cost and Subsidy: Updates prior to exit
Data Collection Instructions:· Required for clients in site-based or scattered-site supportive housing only.
· Update only if housing cost has changed between the last update and program exit. / HMIS Tips:
· If new cost or subsidy is reported, end the previously-recorded HMIS record one day before the start date of the new cost or subsidy.
o Add the new cost or subsidy information below as an additional record. Click “Add” to add another record.
· *If the housing cost or subsidy ended at exit, put an END DATE on the housing cost or subsidy to match the PROGRAM EXIT DATE.
Housing Cost / Housing Subsidy
Start Date / Amount client pays for rent / * End Date / Start Date / Source of Subsidy
(enter # from list below) / * End Date
/ / / $ / / / / / / / / /
1. No subsidy
2. Bridges
3. County Funded / 4. GRH
5. HOME
6. HOPWA / 7. MHFA Rental Assistance
8. Property Subsidy
9. SHP Leasing / 10. Section 8
11. Shelter Plus Care
12. Sons of Bridges
13. Other (specify): ______
6b. What was the client’s subsidy status at program exit?