<p> NC Department of Health and Human Services Division of Aging and Adult Services Housing and Homeless Unit</p><p>NC ESG EMERGENCY SHELTER AND STREET OUTREACH CLIENT FILE CHECKLIST</p><p>Tab 1: Initial Assessment / Eligibility Criteria</p><p>___ 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 </p><p>Additional ESG Documentation ___ Street Outreach (case notes, services, referrals, etc…) ___ Essential Services (case notes, services, referrals, etc…) ___ Shelter Operations (HMIS/DV output delivery notes)</p><p>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)</p><p>Tab 3: Miscellaneous ___ Correspondence </p><p>1.1 NC ESG Emergency Shelter and Street Outreach Client Checklist REV 1.25.17</p>