End-of-Period Discharge Form
Document a person’s exit from a service or facility at the end of a defined period.
Person’s full name
*
Non-sensitive internal reference
Department or service unit
*
Period ending
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for discharge
*
Period completed
Service no longer needed
Transfer to another service
Other
Discharge destination or next service
Belongings or assigned property returned
*
All returned
Some returned
Not applicable
Follow-up required
*
Yes
No
Staff member completing the form
*
Submit
Should be Empty: