Moved to a transitional or temporary housing facility or Data not collected ○ ○ program IF TO MAINTAIN HOUSING AT PROJECT TO HOUSING ASSESSMENT “ABLE Subsidy Information With an subsidy acquired since project Without a subsidy ○ ○ entry Only with financial assistance other than a With the subsidy they had at project entry ○ ○ subsidy IF TO NEW HOUSING UNIT” TO HOUSING ASSESSMENT “MOVED Subsidy Information With subsidy Without an subsidy ○ ○ IN PERMANENT HOUSING Housing Projects, for Heads of Households] No Yes ○ ○ IF TO PERMANENT HOUSING “YES” Housing Move-in Date ____/____/__________ DISABLING CONDITION Clients if to any condition, mark ] – ‘yes’ ‘yes’ No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ PHYSICAL DISABILITY Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO PHYSICAL DISABILITY SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ DEVELOPMENTAL DISABILITY Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DEVELOPMENTAL DISABILITY SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ CHRONIC HEALTH CONDITION Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO CHRONIC HEALTH CONDITION SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○
○ Moved to a transitional or temporary housing facility or program ○ Data not collected IF “ABLE TO MAINTAIN HOUSING AT PROJECT TO HOUSING ASSESSMENT Subsidy Information ○ Without a subsidy ○ With an subsidy acquired since project entry ○ With the subsidy they had at project entry ○ Only with financial assistance other than a subsidy IF “MOVED TO NEW HOUSING UNIT” TO HOUSING ASSESSMENT Subsidy Information ○ With subsidy ○ Without an subsidy IN PERMANENT HOUSING Housing Projects, for Heads of Households] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING Housing Move-in Date ____/____/__________ DISABLING CONDITION Clients – if ‘yes’ to any condition, mark ‘yes’ ] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected PHYSICAL DISABILITY Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO PHYSICAL DISABILITY – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected DEVELOPMENTAL DISABILITY Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected
COHMIS-Exit-form504.docx