<p> HMIS Client ID # (HoH) HUD CoC Exit Form for HMIS: Households</p><p>Program Exit (in HMIS: use Entry/Exit Tab) Name: First Middle Last Suffix HMIS Tips:  Complete Exit from the head of household’s record  Use the General HMIS Instructions, your program’s (funder) Supplemental User Guide, and the Households How-To 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 Assessment.  If some household members are staying, uncheck the boxes next to their names.  After completing the first Exit Data window, Save & Continue to Exit Assessment and answer required questions for each member. A (green check- mark) indicates a household member’s record has been updated.</p><p>Required for all Clients. If information is not the same for all household members, note in margins or use Exit form for Singles</p><p>1. Exit Date: _____ /_____/______</p><p>2. Reason for leaving (optional)  Completed Program  Criminal activity/violence  Unknown/ disappeared  Non-payment of rent  Voluntarily Withdrew From Program  Needs could not be met  Reached Maximum Age Allowed  Left for Housing Opportunity Before Completing Program  Death  Reached Maximum Time Allowed  Non-compliance with program  Other</p><p>3. Destination  Deceased  Permanent Housing (other than RRH) for  Staying or living with family, permanent tenure  Emergency shelter, including hotel or motel paid for formerly homeless persons  Staying or living with family, temporary tenure with emergency shelter voucher  Place not meant for habitation (e.g., a vehicle, (e.g., room, apartment or house)  Foster care home or foster care group home an abandoned building, bus/train/subway  Staying or living with friends, permanent  Hospital or other residential non-psychiatric station/airport or anywhere outside) tenure medical facility  Psychiatric hospital or other psychiatric facility  Staying or living with friends, temporary tenure  Hotel or motel paid for without emergency shelter  Rental by client, no ongoing housing subsidy (e.g., room, apartment or house) voucher  Rental by client, with VASH housing subsidy  Substance abuse treatment facility or detox  Jail, prison or juvenile detention facility  Rental by client, with GPD TIP housing subsidy center  Long-term care facility or nursing home  Rental by client, with other ongoing housing  Transitional housing for homeless persons  Moved from one HOPWA funded project to subsidy (including RRH) (including homeless youth) HOPWA PH  Residential project or halfway house with no  Other (specify) ______ Moved from one HOPWA funded project to homeless criteria  No exit interview completed HOPWA TH  Client doesn't know HUD CoC Exit Form for Households 1 of 6 hmismn.org Last updated 3/7/2018  Owned by client, no ongoing housing subsidy  Safe Haven  Client refused  Owned by client, with ongoing housing subsidy  Data not collected Health Insurance Updates (All Clients) a. New Health Insurance: 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. Health Indian Covered VA Ins. Health State Employ by Childre Medica er- throug State Privat Servic health n’s l Provide h Health e Pay es insuranc Medica Medica Health Servic d Health COBR Ins. for Healt Progra Household Member Name e id (MA) re Ins. es Ins. A Adults h Ins. m Other Start Date 1. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes / / 2. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes / / 3. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes / / 4. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes / / 5. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes / / 6. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes / / b. Health Insurance recorded previously that has since ENDED (not common): Health Insurance Health Insurance Household Member Household Member Name Source (enter name End date Source (enter name End date Name from list above) from list above) / / / / / / / / / / / / Disability Updates (All Clients) a. Does the client have a disability of long duration? HMIS Tips: If answer to question (a) is different than recorded at project start, you must update the answer at project start, NOT update! (Click on the pencil next to project start date) Disability of Long Household Member Name Duration? Yes No  DK  R  1. NC Yes No  DK  R  2. NC</p><p>ESG and ESP Exit Form for Households 2 of 6 hmismn.org Last updated 3/7/2018 Yes No  DK  R  3. NC</p><p> b. Newly Identified Disabilities HMIS Tips: Record a Yes/No/Data not collected response value for each HUD-approved disability type between project start and exit. If there is a change, select the edit pencil next to a 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.) Enter a new response value 1 day after end date for that disability type using the Add button. Ensure that the HUD Verification step is complete. Star Disability If Yes, Expected to be of long-continued and Household Member Name (repeat client t (record # from Disability determination indefinite duration and impairs ability to live name if multiple disabilities are present) Dat list below) independently? e e Yes No DK R NC t Yes No DK R NC a D</p><p>Yes No DK R NC t Yes No DK R NC i x</p><p>Yes No DK R NC E Yes No DK R NC</p><p> t</p><p>Yes No DK R NC c Yes No DK R NC e j o</p><p>Yes No DK R NC r Yes No DK R NC P</p><p> e Yes No DK R NC s Yes No DK R NC U</p><p>1. Mental Health Problem (HUD) 5. Alcohol abuse (HUD) 9. Traumatic brain injury 2. Physical Disability (HUD) 6. Drug abuse (HUD) 10. Hearing impaired 3. Developmental Disability 7. Both Alcohol and Drug Abuse (HUD) 11. Vision impaired (HUD) 8. HIV/AIDS (HUD) 12. Other (Specify) 4. Chronic Health Condition (HUD) c. Disabilities recorded previously that have since ENDED (not common): Household Member Name (repeat Disability (enter Household Member Disability (enter client name if multiple disabilities have End date End date name from list above) name from list above) ended) Name / / / / / / / / / / / /</p><p>Housing Assessment at Exit (Homelessness prevention projects only) (All Clients)</p><p>ESG and ESP Exit Form for Households 3 of 6 hmismn.org Last updated 3/7/2018  Able to maintain the housing they had at project  Client became homeless – moving to a shelter or another place unfit for human habitation entry  Client went to jail/prison  Moved to new housing unit  Client died  Moved in with family/friends on a temporary basis  Client doesn’t know  Moved in with family/friends on a permanent basis  Client refused  Moved to a transitional or temporary housing facility  Data not collected or program If “Able to maintain housing they had at project entry,” Subsidy Information (Homelessness prevention projects only) (All Clients)  Without a subsidy  With the subsidy they had at project entry  With an on-going subsidy acquired since project entry  Only with financial assistance other than a subsidy</p><p>If “Moved to new housing unit,” Subsidy Information (Homeless prevention projects only) (All Clients)  With on-going subsidy  Without an on-going subsidy  Data not collected Income Sources/Amounts Updates (All Adults and Heads of Household) a. New Income Sources/Amounts: Data Collection Instructions: Collect HMIS Tips: Record a Yes/No/Data not collected response value for each HUD-approved monthly income type income information for all household between project start and exit. If there is a change, select the edit pencil next to an income type to add an end members. Income received on behalf of date. (“Receiving income source” should remain “Yes” even after the income ends.) Enter a new response value 1 minors should be recorded on the day after end date for that income type using the Add button. Ensure that the HUD Verification step is complete parent's/guardian's record. Total Source 1 Source 2 Monthl Income Monthly HoH/Adult Household Member (enter # Monthly (enter # y from any Start Date Start Date Income Name from List Amount from List Amoun source from ALL Below) Below) t Sources 1. Yes / / $ / / $ $</p><p>2. Yes / / $ / / $ $</p><p>3. Yes / / $ / / $ $ 1.Earned Income (HUD) 8. TANF (MFIP) (HUD) 15. Contributions from other people 2.Unemployment insurance (HUD) 9. General Assistance (HUD) 16. Interest, dividends, or annuities 3.SSI (HUD) 10. Retirement income from Social Security 17. MSA/Minnesota Supplemental Aid 4.SSDI (HUD) 11. VA Non-Service Connected Disability Pension (HUD) 18. Student grants/scholarship 5.VA Service Connected Disability Compensation 12. Pension or retirement income from a former job (HUD) 19. Tribal Funds ESG and ESP Exit Form for Households 4 of 6 hmismn.org Last updated 3/7/2018 (HUD) 13. Child support (HUD) 20. Other (specify) (HUD) 6.Private disability insurance (HUD) 14. Alimony or other spousal support (HUD) 7.Worker’s compensation (HUD) b. Income sources recorded previously that have since ENDED: List below with end dates: Income Source 1 (enter Income Source 2 (enter Household Member Name End date End date name from list above) name from list above)</p><p>1. / / / / 2. / / / / 3. / / / /</p><p>Non-Cash Benefits Updates (All Adults and Heads of Household) a. New Non-Cash Benefit Sources: Data Collection Instructions: Record non- HMIS Tips: Record a Yes/No/Data not collected response value for each HUD-approved non-cash benefit cash benefits for each adult and head of type between project start and exit. If there is a change, select the edit pencil next to a non-cash benefit type household. Non-cash benefits generally apply to to add an end date. (“Receiving benefit?” should remain “Yes” even if the benefit ends.) Enter a new all members of the household who benefit, even response value 1 day after end date for that non-cash benefit type using the Add button. Ensure that the indirectly. HUD Verification step is complete. Non-cash Source 2 (enter Source 1 (enter # HoH/Adult Household Member Name benefit from Start Date # from List Start Date from List Below) any source Below) 1. Yes / / / /</p><p>2. Yes / / / /</p><p>3. Yes / / / /</p><p>1. Supplemental Nutrition Assistance Program (Food Stamps) (HUD) 4. TANF transportation services (HUD) 2. Special supplemental nutrition program (WIC) (HUD) 5. Other TANF-Funded Services 3. TANF Child Care Services (HUD) 6. Other Source (specify) (HUD) b. Non-cash benefits recorded previously that have since ENDED: List below with end dates:</p><p>ESG and ESP Exit Form for Households 5 of 6 hmismn.org Last updated 3/7/2018 Benefit Source 1 (enter Benefit Source 2 (enter Household Member Name End date End date name from list above) name from list above)</p><p>1. / / / / 2. / / / / 3. / / / /</p><p>HoH/Adult Household Member Name Date of Contact Staying on Street, ES, or SH? / /  Yes  No  Worker unable to determine / /  Yes  No  Worker unable to determine / /  Yes  No  Worker unable to determine (Street Outreach or Night by Night clients only)</p><p>CoC of Service (Head of Household)  MN-500 Hennepin  MN-503 SMAC  MN-506 Northwest  MN-511 Southwest  MN-501 Ramsey  MN-504 Northeast  MN-508 West Central  MN-502 Southeast  MN-505 Central  MN-509 St. Louis Assessment Disposition (Coordinated Assessment projects; Any project type conducting a coordinated assessment) (Head of Household)  Referred to emergency shelter/safe  Referred to a homelessness diversion program haven  Unable to refer/accept within continuum; ineligible for continuum projects  Referred to transitional housing  Unable to refer/accept within continuum; continuum services unavailable  Referred to rapid re-housing  Referred to other community project (non-continuum)  Referred to permanent supportive  Applicant declined referral/acceptance housing  Applicant terminated assessment prior to completion  Referred to homelessness prevention  Other/specify  Referred to street outreach If Other Assessment Disposition, please specify:  Referred to other continuum project type</p><p>Underlined terms have definitions provided at hmismn.org. Please print a copy to have available.</p><p>ESG and ESP Exit Form for Households 6 of 6 hmismn.org Last updated 3/7/2018</p>