HMIS Requests

Agency Name (required)

Program Name (required)

Report Type (required)
---APRData QualityCustomOther

Type of Data (please check all that apply)
Demographics (Race, Ethnicity, Gender, Age)Outcomes (Examples: Increased income, increased employment, increased non-cash benefits)Exit DestinationsTrack length of stay in programsClient level, program level, program type, system wide, and aggregate reportingVeterans, youth, special populations (HIV/AIDS, substance abuse, mental health issues, physical disability, domestic violence, etc.)Other (please describe in box below)
Other:

Report Range (required):
Start Date: End Date:

For Custom Reports (include as much detail as possible, and/or examples.If not applicable, please type N/A)

1. What specifically do you want reported?

2.Please provide a description of how the report should look (i.e. tables only, cross tabs, Portrait vs Landscape, etc.)

Desired Date of Completion (required):

Contact Name (required):

Contact Email (required):

Contact Telephone (required):

Agency*

Name of Agency Representative*

Email*

Project Name*

Which Continuum of Care (CoC) will the project be providing services in? (Please choose only one. If your project is multi-jurisdictional, separate projects must be set up within each CoC):*
---GVPHC VA-505SVHC VA-501Virginia Beach VA-503Lynchburg VA-508

Operating Start Date*

Federal Partner Funding Source*
---HUD CoC: Permanent Supportive HousingHUD CoC: Rapid RehousingHUD CoC: Supportive Services OnlyHUD CoC: Transitional HousingHUD ESG: Emergency ShelterHUD ESG: PreventionHUD ESG: Rapid RehousingHUD ESG: Street OutreachHUD HOPWAHHS PATHHHS RHYVeterans AffairsNone

Grant Identification Number

Grant Start Date

Grant End Date

Bed Inventory* (Please provide the total program capacity. If a prevention program please enter 0.)

Household Type:*
Households without children (adults only)Households with at least one adult and one childHouseholds with only children

Project Type:*
---Coordinated AssessmentDay ShelterEmergency ShelterHomelessness PreventionPermanent Housing with Services (no disability required for entry)Permanent Supportive Housing (disability required for entry)Rapid RehousingServices OnlyStreet OutreachTransitional Housing

Housing Type:*
---Site-based: single siteSite-based: clustered/multiple sitesTenant-based: scattered siteNot a housing program

Will the data entered into this project be shared with other providers in the system?*YesNo

If your agency is currently participating in HMIS, please list the first and last names of all HMIS users who will need access to this project within your agency (please enter “all” if the project should be open to all users). If not, please type in NA (new agencies must meet with the system administrator for training prior to setting up projects):*

Optional: If this project will be tracking Services provided to clients, please list which services should be in the Quicklist (i.e., Housing Counseling; Rent Payment Assistance, Rental Deposit, Utility Assistance, etc.):*

Please briefly describe the project:*

This form will be submitted to The Planning Council. We are currently experiencing a high volume of requests; please allow at least one week for this project setup to be completed. If you have any questions, you may call (757) 622-9268 ext. 3040.

Agency:*

License Type:*
---New LicenseExisting License

Is an Advanced Report Tool (ART) License Required?*
YesNo

Name of Existing Licensee (if applicable)

Name of New Licensee:*

New Licensee Email*

New Licensee Phone*

Please list the HMIS project(s) you will be entering data into:*

Please enter the dates and times licensee will be available to meet for training (minimum of 3 options, please). Note: We are currently experiencing a high volume of requests; please offer dates at least 2 weeks out from today.*

Notice: All new licensees must be trained by a System Administrator and sign a New User Agreement. New agencies must have a signed Agency Agreement, and a System Demonstration is highly recommended. If you have any questions, please contact The Planning Council at (757) 622-9268.

Agency:*

Name:*

Email:*

Phone Number:*

Please list the HMIS project(s) you will be entering data into:*

How many users will be attending the training?*

Please enter the dates and times licensee will be available to meet for training (minimum of 3 options, please). Note: We are currently experiencing a high volume of requests; please offer dates at least 2 weeks out from today.*

Notice: All new licensees must be trained by a System Administrator and sign a New User Agreement. New agencies must have a signed Agency Agreement, and a System Demonstration is highly recommended. If you have any questions, please contact The Planning Council at (757) 622-9268.

Agency:*

Name:*

Email:*

Upload File:

Agency:*

Name:*

Email:*

Phone Number:*

Questions or Comments (If requesting Technical Assistance, please reference Client IDs only, no names!):*