VHPD HMIS DATA: PROGRAM EXIT FORM

Transcription

1 VHPD HMIS DATA: PROGRAM EXIT FORM FOR TEXT FIELDS, USE BLOCK LETTERS. OTHERWISE, MARK APPROPRIATE BOXES WITH AN X Fill out separate form for each household member and clip together. PROGRAM EXIT DATE (e.g., 05/24/2010) [All clients] / / Month Day Year CURRENT NAME (first, middle, last name, suffix (e.g., Jr, Sr, III)) [All clients] First name Middle name Last name Suffix N/A Client does not know Client refused to provide SOCIAL SECURITY NUMBER [All clients] - - HOUSING STATUS [All clients] Literally homeless Imminently losing their housing Unstably housed and at-risk of losing housing Stably housed Client does not know Client refused to provide REASON FOR LEAVING [All Clients] If client left for multiple reasons, record only the primary reason Left for a housing opportunity before completing Needs could not be met by program program Completed program n-payment of rent/occupancy charge n-compliance with program Criminal activity/destruction of property/violence Reached maximum time allowed by program Disagreement with rules/persons Death Unknown/disappeared Other: (Describe) INCOME AND SOURCES [All clients] Have you received any income from any source over the last 30 days? Client does not know Yes Client refused to provide VHPD HMIS Data: PROGRAM EXIT FORM 5/6/2011 1

2 [IF YES] Please state whether you have received income from the following sources within the last 30 days. If you have received income from a source, state the of income you received in the last 30 days. Receiving income Source of income from source? Amount from source (round to nearest dollar) Earned income (i.e., employment income) Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Veteran s disability payment Private disability insurance Worker s compensation Temporary Assistance for Needy Families (TANF) General Assistance (GA) Retirement income from Social Security Veteran s pension Pension from a former job Child support Alimony or other spousal support Other source Total monthly income NON-CASH BENEFITS [All clients] Did you receive any non-cash benefits over the last 30 days? Yes Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Yes $. 0 0 Client does not know Client refused to provide Yes $. 0 0 Monthly income from all sources $. 0 0 VHPD HMIS Data: PROGRAM EXIT FORM 5/6/2011 2

3 [IF YES] Which of the following non-cash benefits have you received over the last 30 days? Received benefit? Yes Source of non-cash benefit Supplemental Nutrition Assistance Program (SNAP) (Formerly known as Food Stamps) MEDICAID health insurance program MEDICARE health insurance program State Children s Health Insurance Program (SCHIP) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Veteran s Administration (VA) Medical Services TANF Child Care services TANF transportation services Other TANF-Funded Services Section 8, Public Housing, or other rental assistance Other source: Temporary rental assistance DISABILITY TYPES [All clients] Do you have a disability that is expected to be of long-continued duration and substantially impairs your ability to live independently? Client does not know Yes Client refused to provide [IF YES] Indicate the disability types below? PHYSICAL DISABILITY [All clients] Yes Client does not know Client refused to provide CHRONIC HEALTH CONDITION [All clients] Yes Client does not know Client refused to provide MENTAL HEALTH [All clients] Yes Yes Client does not know Client refused to provide Yes Client does not know Client refused to provide Yes VHPD HMIS Data: PROGRAM EXIT FORM 5/6/2011 3

4 Client does not know Client refused to provide Client does not know Client refused to provide [IF YES] Is the problem expected to be of long-continued duration and substantially impairs ability to live independently? Yes SUBSTANCE ABUSE [All clients] Client does not know Client refused to provide Alcohol abuse Yes Drug Abuse Client does not know Both alcohol and drug abuse Client refused to provide Client does not know Client refused to provide [IF YES] Is the problem expected to be of long-continued duration and substantially impairs ability to live independently? Yes Client does not know Client refused to provide VHPD HOUSING RELOCATION & STABILIZATION SERVICES PROVIDED [All clients] Check ( or X) all services that were provided during each start and end date. Time between start and end dates can not exceed three months. Start date End date Case management Outreach and engagement Housing search and placement Legal services Credit repair VHPD HMIS Data: PROGRAM EXIT FORM 5/6/2011 4

5 VHPD FINANCIAL ASSISTANCE PROVIDED [All clients] Start date End date Rental assistance Utility payment Security deposit Utility deposit Moving costs Motel/hotel voucher Total VHPD EMPLOYMENT [All Adults and Unaccompanied Youth] Is the client currently employed? Client does not know Yes Client refused to provide [IF NO] Is the client looking for work? Yes Client does not know Client refused to provide VHPD HMIS Data: PROGRAM EXIT FORM 5/6/2011 5

6 [IF YES] Number of hours worked in the past week? Number of Hours Worked in the past week Client does not know Client refused to provide Is the work permanent, temporary or seasonal? Permanent Temporary Client does not know Client refused to provide Seasonal Is the client looking for additional employment or increased hours at their current job?? Yes Client does not know Client refused to provide DESTINATION [All Clients] Emergency shelter, including hotel or motel paid for with emergency shelter voucher Transitional housing for homeless persons (including homeless youth) Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO Mod Rehab) Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non psychiatric) Jail, prison, or juvenile detention facility Staying or living with family, temporary tenure (e.g., room, apartment or house) Staying or living with friends, temporary tenure (.e.g., room apartment or house;) Staying or living with family, permanent tenure Staying or living with friends, permanent tenure Hotel or motel paid for without emergency shelter voucher Foster care home or foster care group home Place not meant for habitation (e.g. a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) Other: (Describe) Safe Haven Rental by client, with VASH housing subsidy Rental by client, with other (non-vash) housing subsidy Owned by client, with ongoing housing subsidy Rental by client, no ongoing housing subsidy Owned by client, no ongoing housing subsidy Client does not know Client refused to provide VHPD HMIS Data: PROGRAM EXIT FORM 5/6/2011 6