CASE NOTES FORM DOCUMENTING
AT RISK OF HOMELESSNESS
State
Project Name
Attach any supporting documentation and/or additional pages as needed for case notes.
I have determined that (Name of Participant)
is at risk of
homelessness because the individual is likely to become homeless, lacks the resources and
support networks needed to obtain housing, and the risk of homelessness is real and
imminent.
The condition(s) that best describe(s) the individual’s risk of homelessness (check all that
apply):
His/her rent or mortgage has been unpaid or overdue, or he/she is unable to pay
rent/mortgage most months
She/he often borrows money to pay rent/mortgage
His/her real estate taxes are unpaid or overdue
She/he is temporarily sharing space with a family member or friend
He/she has involuntarily moved several times in the last year
Her/his credit history or background disqualifies her/him from most rental/lease
agreements
He/she frequently has unpaid or overdue electric/gas/water bills
She/he has been evicted from a residence in the last 12 months
He/she has lived in a shelter during the past 12 months
Other (describe):
I have provided below (or attached) details for each of the conditions checked to show
how the condition is putting participant at risk.
I believe the risk is real and imminent (i.e., the participant is likely to become homeless within
the next few months if nothing changes) because:
Other pertinent information that supports the “at risk of homelessness” determination (can
reference here other types of validation used, such as participant self-attestation):
CASE NOTES FORM DOCUMENTING
AT RISK OF HOMELESSNESS
CONTINUED
I did / did not (circle one) receive information from additional sources to support this
assessment. If I did, information regarding that source or sources is provided below.
Name(s), title/organization or relationship to participant
Phone number(s):
Date(s) information obtained for each source listed:
Signature or name of individual completing these case notes
Date(s) information was obtained for these case notes:
Date case notes were recorded:
Eff. 8/10/11
Standard Requirements for Case Notes to Validate Most-in-Need Factors
Every case note used to validate data must include the specific facts being documented
and meet the following minimal standards:
1. Case notes must include the name of person who is source of info., phone #,
and person’s organization/title or relationship to participant, whichever is
appropriate.
2. Case notes must include name or initials of person making the note.
3. Case notes must contain the date on which the information was obtained, and
the date on which it was recorded, if different.
Many MIN factors require additional information in the form of detailed case notes that go
beyond the minimal case note standards. The information below provides guidance on
what is required for documenting at risk of homelessness using detailed case notes.
DOL Requirements for Validating At Risk of Homelessness Using Detailed Case Notes
At risk for homelessness means an individual is likely to become homeless, and the individual
lacks the resources and support networks needed to obtain housing. The risk must be real
and imminent. Although anyone living below the poverty level may be at risk of
homelessness, this MIN factor requires a more specific and identifiable risk than just low
income. In addition to the standard case note requirements, detailed case notes must show
how the participant meets the definition of “at risk”. Examples of conditions that may
indicate a risk are listed on the first page of this form. Case notes are especially important
when it is not obvious why the condition(s) the participant is experiencing are likely to result
in imminent homelessness.
When to Use Case Notes Instead of or in Addition to Other Validation
Enrollment should not be held up while waiting for documentation for this Most In Need (MIN)
Factor. The MIN should be entered as a “No”, and then changed to a “Yes” on the
application form once documentation is complete. In instances where documentation is
delayed, additional case notes must be kept documenting the steps/actions taken from
initial MIN assessment to final determination.
Official/business records, third party attestation, or self-attestation are allowable to
document at risk of homelessness. However, case notes may be needed in some cases to
provide sufficient detail to show how participant meets the “at risk of homelessness”
definition. For example, written notice of unpaid rent for a single month may be the result of
the individual simply being late with a payment. Or it could be the first step in possible
eviction because the participant has no financial resources left and no support network to
draw on. Case notes would clarify which is the case and whether the participant meets the
MIN criterion.
Eff. 8/10/11