HMIS Program Exit 6-2010

NewHampshireContinuaofCare

HUD COC APR TH PH ESExit Formfor HMIS

(Required byHUDfor eachclient exiting yourproject)

Refer to the2014HUD HMIS Data Standards Version 5.1on the NH-HMIS website at for an explanation of the data elements in this form.

Projectexit –The following data elements must becollected ateveryprojectexit. Like projectentrydata, aclientmusthaveonlyonevaluefor each ofthesedataelementsin relationtoaspecificprojectenrollment, butaclientcould havemultiple projectexits andexit data associated with each. Thedataon this form mustaccuratelyreflecttheclient’s responseor circumstanceas ofthe dateof projectexit. Edits madetocorrecterrorsor improvedata qualitywillnotchangethedatacollectionstageor the informationdate. Elements collected atprojectexitmusthaveanInformationDate that matchestheclient’s ProjectExitDateandaData CollectionStageof ‘projectexit.’ InformationmustbeaccurateasoftheProjectExit Date.

Data Collection and HMIS Instruction Tips:

Use this form to exit clients from your project.

Do NOT enter “Client doesn’t know” or “Client refused” unless the client tells you they do not know or they refuse to answer.

Date Form Completed: __ __/ __ __/ ______
Case Manager’s Name: ______/ Client’s Project ExitDate: ______/______/______
CoC Location exiting from: BOS  MCOC  GNCOC
Client’s First, Middle, Last Name, Suffix:
Client’s ID #: ______

Section 1: Reason for Leaving & Destinationat Exit (in ServicePoint use Entry/Exit Tab)

Record services that have been provided as of the project exit date.

Exit Date: ____/____/______
Reason forleaving (chooseone):
Completedprogram / Disagreementwithrules/persons / Non-compliance with program
Criminalactivity/violence / Housingopportunity before completing / Non-payment ofrent
Death / Needs couldnotbemet / Reachedmaximum timeallowed
Unknown/Disappeared / Other(specify)______
Destination(chooseone):
Deceased / Rentalbyclient,no ongoing housing subsidy
Emergencyshelter,includinghotel or motel paid with
emergencysheltervoucher / Rentalbyclient,with VASHsubsidy
Fostercarehomeor fostercaregrouphome / Rentalbyclient,with GPD TIPsubsidy
Hospitalor other residential non-psychiatric medical
facility) / Rentalbyclient,with other ongoing housingsubsidy
Hotelor motelpaidforwithoutemergencysheltervoucher / Residential project or halfway house with no homeless criteria
Jail,prisonor juveniledetentionfacility / SafeHaven
Long-term care facility or nursing home / Stayingor livingwith family, permanent tenure
Moved from one HOPWA funded project to HOPWA - PH / Stayingor living with family, temporary tenure (e.g., room,
apartment or house)
Moved from one HOPWA funded project to HOPWA - TH / Stayingor livingwith friends, permanent tenure
Ownedbyclient,noongoinghousingsubsidy / Stayingor living with friends, temporary tenure (e.g., room,
apartment or house)
Ownedbyclient,withongoinghousingsubsidy / Substanceabusetreatmentfacilityor detoxcenter
Permanenthousingforformerlyhomelesspersons (such as:
CoC project; HUD legacy programs, or HOPWA PH) / Transitionalhousingforhomelesspersons(includinghomeless
youth)
Placenotmeantforhabitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere
outside) / Client doesn’t know
Client refused
No exit interview completed
Psychiatric hospital or other psychiatric facility / Data not collected
Other
If “Other,” please specify:

Section 2: Health Insurance at Exit (in ServicePoint use Exit Tab)

Update if information changed at exit.

Date of information collection: ______/______/______
Covered by health insurance?NoYesClient doesn’tknowClient refused Data not collected
MEDICAID / NoYes
MEDICARE / NoYes
State Children’s Health Insurance Program (or use local name) / NoYes
Veteran’s Administration (VA) Medical Services / NoYes
Employer-Provided Health Insurance / NoYes
Health insurance obtained through COBRA / NoYes
Private Pay Health Insurance / NoYes
State Health Insurance for Adults / NoYes
Indian Health Services Program / NoYes
Other (or use local name) / NoYes
If “other,” please specify:

Section 3: Disabilityat Exit (in ServicePoint use Entry/Exit Tab)

Does the client have a disabling condition?

Yes / No / Client doesn’t know / Client refused

Disability Type:Answer the group of questions below associated with each applicable disability type, using HUD verification. This information should be collected for all clients, regardless of age.

Physical Disability