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

    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!

    Agency & Project Location Information
    Primary Agency Address [REQUIRED]

    Address Type:





    Is the project address the same as the agency address?

    Project Address [IF DIFFERENT FROM PRIMARY ADDRESS]

    Address Type:





    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.




    Would you like to add a Secondary Liaison?

    Alternate/Backup Agency Liaison Contact Information




    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.


    Project Type:*

    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:*

    Provider Grant Type:*

    Service Transaction Workflow:*

    HUD Standards Information – Housing Projects Only (For each item, select only one option)

    Housing Type:*

    Target Population:*

    Method for Tracking Emergency Shelter Utilization:*


    Bed and Unit Inventory (ES/TH/RRH/PSH Projects only)

    Bed Inventory

    Household Type:*

    Bed Type (Facility-based or Voucher):*

    Availability (Year-round or Seasonal):*






    McKinney Vento Funding :*







    Areas Served: (All Project types)

    Geography Served:
    County:*
    City:*

    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.

    1. Choose one service as the primary service for the PROJECT, not the entire agency.
    2. Identify a few services done often but not your primary service. (Optional)
    3. Identify a few services done occasionally but not your primary service. (Optional)
    4. From the services listed above, identify which services you need in the services quick dropdown list. (maximum of 10 items)
    5. Identify providers that your project will make referrals to. If you know them, please provide the EDA numbers.





    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?

    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


    Contract Administrator at Funding Agency/Jurisdiction:


    Contract period:


    Are the costs for new HMIS licenses included in the contract? if unsure check NO *
    If HMIS licenses included, how many users?*

    Additional Comments?