FHPAP Exit Form for HMIS: HOUSEHOLDS
Head of Household Name ___________________
First
____________
___________________ _____
Middle
Last
HMIS ID: ______________
Suffix
HMIS Instructions: (From the head of household’s record)
 EDA to Entry Provider. No need to backdate.
 From Summary Tab or Entry/Exit Tab: click the pencil next to the exit date on the program entry you want to exit. OR
 If some household members are staying, uncheck the boxes next to their names.
 Record the “exit date”.
 Continue to Exit FHPAP Assessment & answer required questions for each member. A
indicates a household member’s record has been updated
 Underlined terms are defined at the end of the form.
Section 1: Exit Information (IN HMIS: use Entry/Exit Tab) If exit information is not the same for all household members, note in margins or use
FHPAP Exit form for Singles
1. Exit Date: _____ /_____/ _______
2. Destination: Where will the clients live after leaving the program?
 Deceased
 Emergency shelter, including hotel or motel
paid for with emergency shelter voucher
 Foster care home or foster care group home
 Hospital or other residential non-psychiatric
medical facility
 Hotel or motel paid for without emergency
shelter voucher
 Permanent housing for formerly homeless
persons (such as: CoC project; or HUD
legacy programs; or HOPWA PH)
 Staying or living with family, permanent tenure
 Place not meant for habitation (e.g., a vehicle,
an abandoned building, bus/train/subway
station/airport or anywhere outside)
 Staying or living with friends, permanent
tenure
 Psychiatric hospital or other psychiatric facility
 Rental by client, no ongoing housing subsidy
 Jail, prison or juvenile detention facility
 Rental by client, with VASH housing subsidy
 Long-term care facility or nursing home
 Rental by client, with GPD TIP housing
subsidy
 Moved from one HOPWA funded project to
HOPWA PH
 Moved from one HOPWA funded project to
HOPWA TH
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing housing
subsidy
 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)
 Substance abuse treatment facility or detox
center
 Transitional housing for homeless persons
(including homeless youth)
 Rental by client, with other ongoing housing
subsidy
 Other (specify) ______________
 Residential project or halfway house with no
homeless criteria
 Client doesn't know
 Safe Haven
 No exit interview completed
 Client refused
 Data not collected
FHPAP Exit form for HOUSEHOLDS
Last updated 10/01/2015
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Section 2: Housing Status/Income/Non Cash Benefits Updates (In HMIS: Entry/Exit Tab)
1.
Housing status (at destination) (All clients)




Category 1 – Homeless
Category 2 – At imminent risk of losing housing
Category 3 – Homeless only under other federal statutes
Category 4 – Fleeing domestic violence
 At-risk of homelessness
 Stably housed
 Client doesn’t know
 Client refused
 Data not collected
2. % of income spent on rent (after leaving the program) (Adults and Heads of Household)
 30% or less of income
 31% to 50% of income
 51% to 65% of income
 66% to 80% of income
 More than 80% of income
3. Date Housed: _____ /_____/ _____
Month
Day
Year
 Not housed at exit
 Not paying rent
Required ONLY for clients who were homeless at entry.
Record the date the clients moved into the house/apartment, or the date the house/apartment became available.
4. Income Updates (Adults and Heads of Household)
Data Collection Instructions
 Collect income information for all household
members. Income received on behalf of minors
should be recorded on the parent's/guardian's
record.
HMIS Instructions
 If income amount for a source has changed: record end date for the old amount one day
before the start date of the new amount. Add new income record for that source using the “Add
button.” Ensure that the HUD Verification step is complete.
 “Receiving income source” should remain “Yes” even after the income ends. (HUD)=HUDapproved income source
4a. New cash income sources/amounts
Adult/HoH
Household Member Name
Cash Income
Received from Any
Source?
1.
2.
3.
1.
2.
3.
4.
5.
6.
Source 1
(enter name
from list
below)
Yes
Yes
Yes
Earned Income (HUD)
Unemployment insurance (HUD)
SSI (HUD)
SSDI (HUD)
VA Service Connected Disability Compensation (HUD)
Private disability insurance (HUD)
7. Worker’s compensation (HUD)
Monthly
Amount
$
$
$
Start Date
/
/
/
8.
9.
10.
11.
12.
Source 2 (enter
name from list
below)
/
/
/
TANF (MFIP) (HUD)
General Assistance (HUD)
Retirement income from Social Security
VA Non-Service Connected Disability Pension (HUD)
Pension or retirement income from a former job
(HUD)
13. Child support (HUD)
14. Alimony or other spousal support (HUD)
Monthly
Amount
$
$
$
Start Date
/
/
/
/
/
/
Total Monthly
Income from
ALL Sources
$
$
$
15.
16.
17.
18.
19.
Contributions from other people
Interest, dividends, or annuities
MSA/Minnesota Supplemental Aid
Student grants/scholarship
Tribal Funds
20. Other (specify) (HUD)
FHPAP Exit form for HOUSEHOLDS
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4b. Income sources recorded previously that have since ENDED: List below with end dates:
Adult/HoH
Household Member Name
Income Source 1
(enter # from list above)
Income Source 2
(enter # from list above)
End date
End date
1.
/
/
/
/
2.
/
/
/
/
3.
/
/
/
/
5. Non-Cash Benefit Updates (Adults and Heads of Household)
Data Collection Instructions
 Record benefits for each person in the household.
 Benefits work opposite of income: if the source indirectly
benefits all household members, it should be recorded for
each person separately.
HMIS Instructions
 Enter new benefit source using the “Add” button. Ensure that the HUD Verification step is
complete. Select the edit pencil next to each benefit type source to add an end date.
“Receiving benefit?” should remain “Yes” even if the benefit ends.
5a. New Non-Cash Benefits
Adult/HoH
Household Member Name
Receiving Benefit
Source 1 (enter name
from List Below)
Start Date
Source 2 (enter name
from List Below)
Start Date
1.
Yes
/
/
/
/
2.
Yes
/
/
/
/
3.
Yes
/
/
/
/
1.
2.
3.
4.
Supplemental Nutrition Assistance Program (Food Stamps) (HUD)
Special Supplemental Nutrition Program (WIC)(HUD)
TANF Child Care Services (HUD)
TANF Transportation services (HUD)
5.
6.
7.
8.
Other TANF-Funded Services (HUD)
Section 8, Public Housing, or other ongoing rental assistance (HUD)
Temporary rental assistance
Other source (HUD) (specify)
5b. Non-cash benefits recorded at entry or at updates that have since ENDED: List below with end dates:
Adult/HoH
Household Member Name
Benefit Source 1 (enter name from
list above)
End date
Benefit Source 2 (enter name from list
above)
End date
1.
/
/
/
/
2.
/
/
/
/
3.
/
/
/
/
FHPAP Exit form for HOUSEHOLDS
Last updated 10/01/2015
3 of 4
www.hmismn.org
Definitions
Housing Status:
Literally Homeless: An individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning:
 Has a primary nighttime residence that is a public or private place not meant for human habitation;
 Is living in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional
housing, and hotels and motels paid for by charitable organizations or by federal, state and local government programs); OR
 Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation
immediately before entering that institution
Imminent Risk of Homelessness: An individual or family who will imminently lose their primary nighttime residence, provided that:
 Residence will be lost within 14 days of the date of application for homeless assistance;
 No subsequent residence has been identified; AND
 The individual or family lacks the resources or support networks needed to obtain other permanent housing
Homeless Under other Federal Statutes: Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify
as homeless as defined above, but who:
 Are defined as homeless under the other listed federal statues;
 Have not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days prior to the homeless assistance
application;
 Have experienced persistent instability as measured by two moves or more during the preceding 60 days; AND
 Can be expected to continue in such status for an extended period of time due to special needs or barriers.
Fleeing/Attempting to Flee DV: Any individual or family who:
 Is fleeing or attempting to flee domestic violence, dating violence, sexual assault, or stalking;
 Has no other residence; AND
 Lacks the resources or support networks to obtain other permanent housing
At-risk of homelessness
 Are currently housed and not literally homeless or imminently losing their housing, per above definitions;
 Are experiencing housing instability, but may have one or more other temporary housing options; and
 Lack the resources or support networks to retain or obtain permanent housing.
Stably housed
 Are in a stable housing situation and not at risk of losing this housing (i.e., do not meet the criteria for any of the other housing response categories,
per above definitions).
FHPAP Exit form for HOUSEHOLDS
Last updated 10/01/2015
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