Please set aside 15-30 mins to fill out the following form in one sitting as it cannot be saved. If you have any questions or need clarification on any of the elements presented, please reach out the the HMIS helpdesk by clicking on the blue support button at the bottom of the page and submitting a ticket. Agency Information Agency Name:* Project Name:* Provider Project Description Describe the primary function/services provided by this project. DO NOT DESCRIBE THE ENTIRE AGENCY FUNCTION, JUST THE FUNCTION OF THIS PROJECT! Description:* Agency & Project Location Information Primary Agency Address [REQUIRED] Address Type: Mailing:Physical:P.O. Box: Address:* City:* State:* Zip:* County:* Is the project address the same as the agency address? YesNo Project Address [IF DIFFERENT FROM PRIMARY ADDRESS] Address Type: Mailing:Physical:P.O. Box: Address: City: State: Zip: County: Contact Information Agency Contact Numbers Main Number* Fax* Agency Liaison Contact Information Definition of Agency Liaison: An Agency Liaison is the person that is the primary contact associated with the project and the person that the HSN HMIS support team communicates with regarding the project. Name:* Title:* Email Address:* Number:* Would you like to add a Secondary Liaison? YesNo Alternate/Backup Agency Liaison Contact Information Name: Title: Email Address: Number: Profile - Provider Profile HUD Standards Information – All Projects (For each item, select only one option) Definitions: Project Type: This HUD term describes the type of housing or services (SSO or OT).The other category is street outreach (SO). Principal Site: Is the address given above as the primary location where this project is implemented? Provider Grant Type: Check “NA” unless your funding comes from Health & Human Services (HHS) or the Veterans Administration (VA). Service Transaction Workflow: Contact HSN HMIS team to discuss this setting. “No” is the correct answer in most cases. Operating Start Date:* Project Type:* ES - Emergency ShelterTH - Transitional HousingRRH - Rapid Re-HousingPSH - Permanent Supportive HousingPH-H - Permanent Housing - Housing OnlyPH-S - Permanent Housing - Services OnlyHP - Homeless PreventionSO - Street OutreachSSO - Supportive Services OnlyOT - Other Housing Type: This is a description of the arrangement/location of the buildings used to house clients. “Tenant-based” is used with vouchers. SSO, SO, or OT projects select “NA”. Target Population: Check “NA” unless your project specifically is funded for one of the other choices. Method for Tracking Emergency Shelter Utilization: Check “NA” unless your project is the “ES” project type above. Principle Site:* YesNo Provider Grant Type:* N/A: Not applicableHOPWA - Housing Opportunities for Persons With AIDSPATH - Projects for Assistance in Transition from HomelessnessSSVF - Supportive Services for Veteran FamiliesRHY - Runaway and Homeless Youth Service Transaction Workflow:* YesNo HUD Standards Information – Housing Projects Only (For each item, select only one option) Housing Type:* N/A: Not applicableSite-based – single siteSite-based – clustered/multiple siteTenant-based – scattered site Target Population:* N/A: Not applicableDV: Domestic violence victimsHIV: Persons with HIV/AID Method for Tracking Emergency Shelter Utilization:* N/A: Not applicableEntry/Exit DateNight-by-night Bed and Unit Inventory (ES/TH/RRH/PSH Projects only) Bed Inventory Bed List Name:* Household Type:* ------Households without childrenHouseholds with at least one adult and one childHouseholds with only children Bed Type (Facility-based or Voucher):* ------Facility basedVoucher Availability (Year-round or Seasonal):* ------Year roundSeasonal Total Bed Inventory:* Total Unit Inventory:* Bed Inventory Start Date:* HMIS Participating Beds:* HMIS Participation Start Date:* McKinney Vento Funding :* YesNo Chronic Homeless Veteran Beds (PSH Only):* Youth Veteran Beds:* Other Veteran Beds:* Chronic Homeless Youth Beds (PSH Only):* Other Youth Beds:* Any Other Chronic Beds (PSH Only):* Non-Dedicated Beds:* Areas Served: (All Project types) Geography Served: County:*OrangeOsceolaSeminole City:*OrlandoKissimmeeSanford Services Provided Instructions: Fill in the table below, based on the details described. Please use service terms given in your contract for services to be provided to clients. Choose one service as the primary service for the PROJECT, not the entire agency. Identify a few services done often but not your primary service. (Optional) Identify a few services done occasionally but not your primary service. (Optional) From the services listed above, identify which services you need in the services quick dropdown list. (maximum of 10 items) Identify providers that your project will make referrals to. If you know them, please provide the EDA numbers. Primary Service:* Secondary Services: Occasional Services: Service Quick List:* Referral Quick List:* Profile - Project Funding & Reporting Requirements These questions are required to ensure your project has access to reports necessary to meet your contract requirements. Effective 8/1/2020, project setup requests without this information, will be returned for incomplete information. This applies to private funding sources as well as jurisdictional funding. We do not need any funding amounts, just date ranges, reporting requirements and services to be provided. Do you have access to your contract? YesNoI'm not sure Who is your contract manager? Best contact for contract information? What does your contract require for reports? (This answer directly impacts assessment choices below) - Reporting requirements (Provide contract page(s) showing requirements)* Funding Agency/Jurisdiction List funding source agency/jurisdiction:* Contract Number or Reference:* Contract Administrator at Funding Agency/Jurisdiction: Name:* Contact Information (Email and/or Phone):* Contract period: Start:* End:* Are the costs for new HMIS licenses included in the contract? if unsure check NO *YesNo If HMIS licenses included, how many users?* Additional Comments?