NC Department of Health and Human Services

NC Department of Health and Human Services Division of Aging and Adult Services Housing and Homeless Unit

NC ESG EMERGENCY SHELTER AND STREET OUTREACH CLIENT FILE CHECKLIST

Tab 1: Initial Assessment / Eligibility Criteria

___ 1.1 NC ESG Emergency Shelter and Street Outreach Client Checklist ___ 1.2 NC ESG Verification of Homelessness form ___ 1.3 NC HMIS Street and Shelter Intake (for most up to date version, go to http://mihomeless.org/index.php/user-resources/north-carolina-users/nc-hmis- assessment-form; DV agencies should use the same form) ___ 1.3-B HMIS Data Collection - Street Outreach Supplemental Form (street outreach only) ___ 1.6-A NC HMIS Client Acknowledgement of Rights (Agencies without sharing agreement) (for most up to date version, log in to nchmis.org or check with Local System Administrator) OR ___ 1.6-B NC HMIS Client Release of Information and Sharing Plan (Agencies with HMIS sharing) (for most up to date version, log in to nchmis.org or check with Local System Administrator) ___ Identification (Units of Gov’t Only): Copy of government issued proof of citizenship (birth certificate, social security card, driver license, passport). ___ ESG Transition Plan

Additional ESG Documentation ___ Street Outreach (case notes, services, referrals, etc…) ___ Essential Services (case notes, services, referrals, etc…) ___ Shelter Operations (HMIS/DV output delivery notes)

Tab 2: HMIS Interim Assessment / Client Exit Strategy ___ 6.2 HMIS / DV Interim Assessment (if needed) (for most up to date version, go to http://mihomeless.org/index.php/user-resources/north-carolina-users/nc-hmis- assessment-form or check with Local System Administrator) ___ 6.3 HMIS / DV Program Exit (for most up to date version, go to http://mihomeless.org/index.php/user-resources/north-carolina-users/nc-hmis- assessment-form or check with Local System Administrator)

Tab 3: Miscellaneous ___ Correspondence

1.1 NC ESG Emergency Shelter and Street Outreach Client Checklist REV 1.25.17