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Licensed Hospital Homeless Discharges 

Please report daily if there has been a discharge of a person to a shelter (in any state) or the street. This report replaces the monthly reporting of the numbers of discharges to shelters or the street. 

Please choose your hospital name carefully from the drop down menu, then enter the specified information for each individual who was discharged to the street or to a shelter. We will eventually provide a drop down menu for the most frequently entered names of shelters as we gather this data from hospitals.

Thank you for helping us to better understand the details involved so that we can work with hospitals and with others in state agencies to reduce the frequency of such discharge dispositions. Please also see the Homelessness Prevention Discharge Planning Decision Tool [link to website when ready] for resources that hospitals can use to better plan discharges for people who are housing insecure.

Please note this survey is being conducted in a HIPAA compliant environment.

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* 1. Hospital

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* 2. Date of Admission

Date

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* 3. Date of discharge

Date

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* 4. Name of person discharged to shelter/street

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* 5. Date of birth

Date

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* 6. Gender

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* 7. Race

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* 8. Name of shelter or Street (Not addresses)

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* 9. Living situation on admission

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* 10. Are there any agencies involved with the person?

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* 11. Did the person submit a three-day notice or found not committable?

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* 12. Status at discharge

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* 13. Email address of person completing form:

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