HMIS Data Collection Template CoC Program Prevention Project Supplemental Form – This form will allow CoC Program-funded Prevention project to track required HMIS Housing Assessment at Exit data. Note that only CoCs designated as High Performing Communities can use CoC Program funds for prevention projects. Respond to the following questions for all household members—each adult and child. A separate form should be included for each household member. CLIENT (name or other identifier) PROJECT EXIT DATE (e.g., 08/24/2017) / / Month Day Year HOUSING ASSESSMENT AT EXIT [IF YES for able to maintain the housing they had Able to maintain the housing they had at project  at project entry] Subsidy Information  Without a subsidy  Moved to new housing unit  With the subsidy they had at project entry Moved in with family/friends on a temporary  basis With an on-going subsidy acquired since  Moved in with family/friends on a permanent project entry  basis Only with financial assistance other than a  Moved to a transitional or temporary housing subsidy  facility or program Client became homeless moving to a shelter or –  other place unfit for human habitation [IF YES for moved to a new housing unit] Subsidy  Client went to jail/prison Information Client died   With an ongoing subsidy Client doesn’t know   Without an ongoing subsidy Client refused 
HMIS Data Collection Template – CoC Program Prevention Project Supplemental Form This form will allow CoC Program-funded Prevention project to track required HMIS Housing Assessment at Exit data. Note that only CoCs designated as High Performing Communities can use CoC Program funds for prevention projects. Respond to the following questions for all household members—each adult and child. A separate form should be included for each household member. CLIENT (name or other identifier) PROJECT EXIT DATE (e.g., 08/24/2017) / / Month Day Year [IF YES for able to maintain the housing they had at project entry] Subsidy Information  Without a subsidy  With the subsidy they had at project entry  With an on-going subsidy acquired since project entry  Only with financial assistance other than a subsidy [IF YES for moved to a new housing unit] Subsidy Information  With an ongoing subsidy  Without an ongoing subsidy HOUSING ASSESSMENT AT EXIT  Able to maintain the housing they had at project  Moved to new housing unit  Moved in with family/friends on a temporary basis  Moved in with family/friends on a permanent basis  Moved to a transitional or temporary housing facility or program  Client became homeless – moving to a shelter or other place unfit for human habitation  Client went to jail/prison  Client died  Client doesn’t know  Client refused
CoC-HMIS-Data-Collection-Template-Prevention-Supplement.docx