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New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
SOP Manchester
 SOP Seacoast
Refer to the 2014 HUD HMIS Data Standards, available on the NH-HMIS website www.nh-hmis.org for an
explanation of the data elements in this form.
Date Form Completed: __ __/ __ __/ __ __ __ __
Outreach Worker for NH: __________________________
Outreach City/Town: ______________________________
First, MI, Last Name, Suffix:
 Full name reported
 Partial, street name, or code name reported
 Client doesn’t know
 Client refused
 Data not collected
Name Data Quality:
Alias:
Client ID Number:
Household ID Number (optional):
Client ID number is generated by the HMIS system.
Household ID number is generated by the HMIS system.
Client Record Creation
SSN: __ __ __ - __ __ - __ __ __ __

SSN Data Quality:  Full SSN Reported
 Client Refused
U.S. Military Veteran?  No
 Yes
 Client Does Not Know or Does Not Have SSN
 Data not collected
 Client doesn’t know
 Partial SSN Reported 
 Client refused  Data not collected
Discharge Type:  Honorable  Uncharacterized  Dishonorable
 General under honorable conditions
 Bad Conduct  Under other than honorable conditions (OTH)
 Client Doesn’t Know
 Client Refused
 Data not collected

Date of Birth:
/
/
 Full DOB Reported
Date of Birth Type:  Approximate or Partial DOB Reported
 Client Doesn’t Know
 Client Refused
Race (client may choose up to 5) :
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
Ethnicity (choose one):  Hispanic/Latino  Non-Hispanic/Non-Latino
 Data not collected
Gender:  Female
 Male
  Client Doesn’t Know  Client Refused
04/14/2015
 Client Doesn’t Know
 Client Refused
 Data not collected
 Client Doesn’t Know
 Client Refused
 Transgender Female to Male  Transgender Male to Female
 Other, (specify) ____________________  Data not collected
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 1 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Entry Assessment
Click Add Entry/Exit. Click to open the Type drop down menu, then select RHY. Click Save and Continue.
Relationship to Head of Household (HoH) (choose one):
 Self
 Head of household’s child
 Head of household’s spouse or partner
 Head of household’s other relation member (other relation to HoH)
 Other: non-relation member __________________________
Outreach
Location (choose one):
 Place not meant for habitation
 Service setting, non-residential
 Service setting, residential
Start Date: ______/______/_________
End Date: ______/______/_________
Date of Contact: ______/______/_________ Time of Contact (Optional)
:
AM PM (Circle one)
Entry Disability
 No  Yes  Client Doesn’t Know  Client Refused
 Data not collected
Information/ Project Entry Date: ____/____/______
Disability Start Date ____/____/______
Disability End Date ____/____/______
Does the client have a disabling condition?
If Yes:
Disability Type
 Physical Disability
 Developmental Disability
 Chronic Health Condition
 HIV/AIDS
 Mental Health Problem
 Substance Abuse Problem
 Alcohol Abuse
 Drug Abuse
  Both Alcohol &
Drug Abuse
If yes, expected to be of longcontinued and indefinite duration
and substantially impairs ability to
live independently?
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
(If yes) Documentation of the
disability and severity on file?
No
No
No
No
No
No
No
No
No
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
(If yes) Currently Receiving
Services or Treatment?
No
No
No
No
No
No
No
No
No
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Disability Note (optional information about disability):
Will above condition be long term?  No
04/14/2015
 Yes
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 2 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Residence Prior to Project Entry (where client stayed the night before project entry):

 Emergency shelter, including hotel or motel paid 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
 Jail, prison or juvenile detention facility
 Long-term care facility or nursing home
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing housing subsidy
 Permanent housing for formerly homeless persons (such as:
CoC project; HUD legacy programs, or HOPWA PH)
 Place not meant for habitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere outside)
 Psychiatric hospital or other psychiatric facility

 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH subsidy
 Rental by client, with GPD TIP subsidy
 Rental by client, with other (non-VASH) ongoing housing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living in a family member’s room, apartment or house
 Staying or living in a friend’s room, apartment or house
 Substance abuse treatment facility or detox center
 Transitional housing for homeless persons (including homeless youth)
 Client doesn’t know
 Client refused
 Other (specify) ___________________________________
 Data not collected
Length of Stay in Previous Place (choose one):
 One day or less
 Two days to one week
 More than one week, but less than one month
 One to three months
 More than three months, but less than one year
 One year or longer
 Client doesn’t know
 Client refused
 Data not collected
 NH-500 (Balance of State/Concord)
 NH-501 (Manchester)
 NH-502 (Nashua)
Length of time on street, in an Emergency Shelter, or Safe Haven:
Client Location (choose one HUD-assigned CoC Code):
 Continuously homeless for at least one year?
No
Yes
Client doesn’t know
Client refused
 Number of times the client has been homeless in the past three years
0
1
2
 3
4 or more
 Client doesn’t know
Data not collected
 Client refused
Data not collected
 If 4 or more, total number of months homeless in the past three years ____
 More than 12 months
Client doesn’t know
Client refused
Data not collected
 Total number of months continuously homeless immediately prior to project entry ____
Note: 1 day to 30 days = 1 month. For example, a client living on the street from mid-July to the day the client enters
emergency shelter on August 5th. This would count as two months.
 Status Documented No
Yes
Note: Indicate if there is documentation in the client’s paper file or in the HMIS of the client’s length of homelessness –
either continuously homeless, the number of times homeless, or the number of months homeless in the past
three years.
04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 3 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Sexual Orientation
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Client Doesn’t know
Client Refused
Data Not Collected
Entry Health Insurance
In ServicePoint, click to select the Entry/Exit tab.
Covered by health insurance?
 No  Yes  Client doesn’t know
If yes, Information/ Project Entry Date: ______/______/________
 Client refused  Data not collected
Health Insurance Source:
If Yes, choose No or Yes below and add dates.
Health Insurance Source
Start Date
End Date
No Yes
No Yes
MEDICAID
MEDICARE
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
State Children’s Health Insurance Program
____/____/______
____/____/______
No Yes
Veteran’s Administration (VA) Medical Services
____/____/______
____/____/______
No Yes
No Yes
Employer-Provided Health Insurance
Health Insurance obtained through COBRA
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
Private pay health insurance
No Yes
State Health Insurance for Adults
____/____/______
____/____/______
____/____/______
____/____/______
Domestic Violence Victim/Survivor?
 No
 Yes
 Client refused
04/14/2015
 Client doesn’t know
 Data not collected
If yes, When Experience Occurred:
 Within the past 3 months  More than a year
 3 - 6 months ago
 Client doesn’t know
 6 - 12 months ago
 Client refused
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 4 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Pregnancy Status
No
Yes
If yes, Due Date: _____/______/_________
Client doesn’t know
Client refused
Commercial Sexual Exploitation
Have you received something in exchange for sex
in the past three months?
No
Yes
Client doesn’t know
Client refused 
Data not collected
If Yes:
Number of times:

If Yes:

Did someone ask/make you
have sex?

04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
1-3
4-7
8-30
More than 30
Client doesn't know
Client refused
Data not collected
Yes
No
Client doesn't know
Client refused
Data not collected

Page 5 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Information Required by BHHS
Housing Status as of the day before project entry:
Homeless and At-Risk of Homelessness Status
 Category 1 – Homeless (lacks fixed, regular, and adequate nighttime residence)
 Category 2 – At imminent risk of losing housing (will lose primary nighttime residence in 14 days)
 Category 3 – Homeless only under other federal statues (unaccompanied youth under 25 years of age, or families with
children and youth, who do not otherwise qualify as homeless under this definition)
 Category 4 – Fleeing domestic violence (when client or household does NOT meet any other criteria but is homeless solely
because they are fleeing domestic violence)
 At-risk of homelessness (for clients being served by Homelessness Prevention or Coordinated Assessment projects)
 Stably housed
 Client doesn’t know
 Client refused  Data not collected
Zip Code data quality:
 Full or Partial
 Client Doesn’t Know  Client Refused
 Data not collected
Zip Code of Last Permanent Address:
(where client last lived 90 days or more)
Entry Employment Status
Employment status is a required element per NH BHHS.
Information Date _____/______/________
Employed?
Yes
If Yes, type of employment?
Full time
Part time

No
Client doesn't know
Client refused
Data not collected
Homeless Status
First Time Homeless?
Yes
No
04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 6 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Services Provided
In ServicePoint, click to select the Service Transaction tab.
Service
Service Date
Street Outreach- Health and Hygiene Products Distributed
______/______/_________
Street Outreach- Food And Drink Items
______/______/_________
Street Outreach- Services Information/Brochures
______/______/_________
Referrals Provided
In ServicePoint, click to select the Service Transaction tab.
Referral
Referral Date
Child Care Non-TANF
______/______/_________
Supplemental Nutritional Assistance Program (Food Stamps)
______/______/_________
Education-McKinney/Vento Liaison Assistance to Remain in School
______/______/_________
HUD Section 8 or Other Permanent Housing Assistance
______/______/_________
Individual Development Account
______/______/_________
Medicaid
______/______/_________
Mentoring Program Other Than RHY Agency
______/______/_________
National Service (AmeriCorps, VISTA, Learn and Serve)
______/______/_________
Non-residential Substance Abuse or Mental Health Program
______/______/_________
Other Public-Federal, State or Local Program
______/______/_________
Private Non-profit Charity or Foundation Support
______/______/_________
SCHIP
______/______/_________
SSI, SSDI or other Disability Insurance
______/______/_________
TANF or other Welfare/Non-disability Income Maintenance (all TANF)
services
______/______/_________
Unemployment Insurance
______/______/_________
WIC
______/______/_________
Workforce Development (WIA)
______/______/_________
04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 7 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
EXIT Data
Exit Reason for Leaving and Destination
In ServicePoint, click to select the Entry/Exit tab
Exit Date: ____/____/________
Reason for leaving (choose one):
 Completed program
 Criminal activity/violence
 Death
 Unknown/Disappeared
 Disagreement with rules/persons
 Non-compliance with program
 Housing opportunity before completing
 Non-payment of rent
 Needs could not be met
 Reached maximum time allowed
 Other (specify)___________________________________________________
Destination (choose one):
 Deceased
 Emergency shelter, including hotel or motel paid 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
 Jail, prison or juvenile detention facility
 Long-term care facility or nursing home
 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
 Permanent housing for formerly homeless persons (such as:
CoC project; HUD legacy programs, or HOPWA PH)
 Place not meant for habitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere
outside)
 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH subsidy
 Rental by client, with GPD TIP subsidy
 Rental by client, with other ongoing housing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living with family, permanent tenure
 Staying or living with family, temporary tenure (e.g., room,
apartment or house)
 Staying or living with friends, permanent tenure
 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)
 No exit interview completed
Exit Date of Engagement : ____/____/________
Optional: If client exits without becoming engaged, the engagement date should be left blank.
04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 8 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Exit Health Insurance
In ServicePoint, click to select the Entry/Exit tab.
Covered by health insurance?
 No  Yes  Client doesn’t know
If yes, Information/ Project Entry Date: ______/______/________
 Client refused  Data not collected
Health Insurance Source:
If Yes, choose No or Yes below and add dates.
Health Insurance Source
Start Date
End Date
No Yes
No Yes
MEDICAID
MEDICARE
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
State Children’s Health Insurance Program
____/____/______
____/____/______
No Yes
Veteran’s Administration (VA) Medical Services
____/____/______
____/____/______
No Yes
No Yes
Employer-Provided Health Insurance
Health Insurance obtained through COBRA
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
Private pay health insurance
No Yes
State Health Insurance for Adults
____/____/______
____/____/______
____/____/______
____/____/______
Exit Disability
 No  Yes  Client Doesn’t Know  Client Refused
 Data not collected
Information/ Project Entry Date: ____/____/______
Disability Start Date ____/____/______
Disability End Date ____/____/______
Does the client have a disabling condition?
If Yes:
Disability Type
 Physical Disability
 Developmental Disability
 Chronic Health Condition
 HIV/AIDS
 Mental Health Problem
 Substance Abuse Problem
 Alcohol Abuse
 Drug Abuse
  Both Alcohol &
Drug Abuse
If yes, expected to be of longcontinued and indefinite duration
and substantially impairs ability to
live independently?
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
No Yes  CDK  CR  DNC
(If yes) Documentation of the
disability and severity on file?
No
No
No
No
No
No
No
No
No
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
(If yes) Currently Receiving
Services or Treatment?
No
No
No
No
No
No
No
No
No
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Yes  CDK  CR  DNC
Disability Note (optional information about disability):
Will above condition be long term?  No
04/14/2015
 Yes
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 9 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Information Required by BHHS
Housing Status as of the day before project entry:
Homeless and At-Risk of Homelessness Status
 Category 1 – Homeless (lacks fixed, regular, and adequate nighttime residence)
 Category 2 – At imminent risk of losing housing (will lose primary nighttime residence in 14 days)
 Category 3 – Homeless only under other federal statues (unaccompanied youth under 25 years of age, or families with
children and youth, who do not otherwise qualify as homeless under this definition)
 Category 4 – Fleeing domestic violence (when client or household does NOT meet any other criteria but is homeless solely
because they are fleeing domestic violence)
 At-risk of homelessness (for clients being served by Homelessness Prevention or Coordinated Assessment projects)
 Stably housed
 Client doesn’t know
 Client refused  Data not collected
Exit Employment Status
Employment status is a required element per NH BHHS.
Information Date _____/______/________
Employed?
Yes
If Yes, type of employment?
Full time
Part time

No
Client doesn't know
Client refused
Data not collected
04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 10 of 11
New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
Fill out this section to help identify a client’s common household members. This information is entered at client program entry.
Head of Household
Is this person the head of a household (households can have only one HoH):
 Yes
 No
If Yes to previous question, please list other members of the household and their relationship to the head of household.
First Name
Last Name
Relationship to Head of
Household*
*CHOOSE:
 Self (head of household)
 Head of household’s child
 Head of household’s spouse or partner
 Head of household’s other relation member (other relation to head of household)
 Other: non-relation member
Important! Please complete the SOP Intake Entry/Exit Form for each person listed above.
This form can be found on the NH-HMIS website at www.nh-hmis.org.
04/14/2015
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
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