Individual Shelter Inappropriate Discharge Reporting Form
This secure form is for individual adult homeless shelter providers to report situations when an individual has come directly from a hospital, nursing facility, behavioral health facility, or other institution and is not appropriate to reside in shelter. The responses will be shared with the Executive Office of Housing and Livable Communities (EOHLC) and the Executive Office of Health and Human Services (EOHHS). While all responses will be reviewed, the information will be utilized primarily for developing and refining a Commonwealth-wide discharge planning policy; individual situations will generally not receive a direct response from either the state nor the discharging facility. If you need a response about a specific situation, please contact the discharging facility directly. EOHHS/EOHLC considers inappropriate discharges to shelter to include: - Situations in which the individual cannot perform basic activities of daily living, including bathing, toileting, and eating without significant support. - Situations in which the individual poses a clear risk to themselves and/or others. - Situations in which the shelter was not contacted before the individual was sent from the facility to the shelter - Situations in which the individual was housed prior to admission and the facility did not pursue available alternatives to shelter These responses are vital so that EOHHS/EOHLC can develop data on the scale of the issue, can identify which facilities may need state intervention, and the specific needs of clients leaving facilities and ending up in shelter.
Reporting person's information
What is the name of your shelter or day program?
(Required)
What is your name?
(Required)
First
Last
What is your email?
(Required)
Discharged person's information
Discharged Person's name
First
Last
Discharged Person's Date of Birth
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Discharging facility's information
What is the name of the discharging facility?
(Required)
Where is the discharging facility located (complete as much as you know)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Information about the discharge
Did you speak with the discharging facility?
(Required)
No
Yes
If you spoke to someone at the discharging facility, what was their name and title (if known)?
If you spoke to someone at the discharging facility, what is their phone and/or email (if known)?
If you spoke to someone at the discharging facility, did they indicate that they had worked with the individual to (re)connect with friends, family etc. as part of the efforts to locate a housing option? If yes, please describe.
When did the discharge occur?
(Required)
MM
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Why do you believe the discharge to shelter was inappropriate?
(Required)