SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 68: DISCHARGE/PROGRAM DEPARTURE FORM INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1995). Module 68: Discharge/Program Departure Form. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

 

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the side of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

 

Specific Parts of the Module 68: HIV Discharge/Program Departure Form

 

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

 

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form.

 

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

 

Discharge Date. Enter the numbers representing the discharge date in these boxes. Enter the month as a number from 01 to 12 for January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "95" for 1995). Make sure that if a month or day is less than 10, you place a "0" before the number.

 

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure than each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the staff who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

 

DEFINITION OF DISCHARGE/PROGRAM DEPARTURE: A client is considered discharged or departed from the program when the service provider knows that the client will not return for services. This definition may vary from site to site. If there are any questions about the definition of discharge, check with your project director.

 

Reason for Discharge (all that apply). Darken the circle(s) next to the response(s) that indicates the reason for the client’s discharge or departure. In the boxes provided to the right of "Other," you may write in a reason for discharge that is not listed. The definitions for the reasons for discharge are listed below.

 

Reason Working Definition
Normal end of program Client was discharged because he/she finished the prescribed course of treatment.
Client left program against advice Program staff did not want to discharge client, but client left the program.
Client was asked to leave program Client was asked to leave the program by program staff.
Moved to another services catchment area Client moved to another catchment area with other service providers.
Moved to a hospice, discharged from the program Client was discharged because he/she was moved to a hospice.
Hospitalized Client was discharged because he/she was hospitalized.
Incarcerated in criminal justice system Client was discharged because he/she was incarcerated.
Institutionalized in mental health system Client was discharged because he/she was admitted as an inpatient in a mental health institution.
Institutionalized in substance abuse program Client was discharged because he/she was admitted as an inpatient in a substance abuse program.
Death Client died.
Services not needed now Client was discharged because he/she no longer needed services at this time.
Lost Program lost contact with client and is unable to find client.
Client refused services Client was discharged because he/she refused services at this time.
Referred out Client was referred to another agency or service provider.
Other Client was discharged for a reason not listed here. Specify the reason in the boxes provided.
Unknown The reason for client’s discharge is unknown.

Module 68

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