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 while filling out this document, please submit a Helpdesk request through our HMIS Helpdesk by visiting www.hmiscfl.org and clicking on the blue "support" button, or by sending an email to hmis@hsncfl.org 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:* Project Location Information Project Address [REQUIRED] Address:* City:* State:* Zip:* County:* Contact Information 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: Emergency Shelter (ES): A project that offers temporary shelter (lodging) for people experiencing homelessness. Transitional Housing (TH): A project that provides temporary lodging and is designed to facilitate movement into permanent housing within a specified period of time (but no longer than 24 months). Rapid ReHousing (RRH): A permanent housing project that provides short-term or medium-term rental assistance and supportive services to people experiencing homelessness. Permanent Supportive Housing (PSH): A project that offers long-term permanent housing and supportive services to people experiencing homelessness with a disability. Permanent Housing - Housing Only (PH-H): A project that offers permanent housing for people experiencing homelessness but does not make supportive services available as part of the project. Permanent Housing - Housing & Services (no disability required for entry) (PH-S): A project that offers permanent housing and supportive services to assist people experiencing homelessness to live independently but does not limit eligibility to people with disabilities. Homelessness Prevention (HP): A project that offers services and/or financial assistance necessary to prevent a person from entering emergency shelter or a place not meant for habitation. Street Outreach (SO): A project that offers services necessary to reach out to people experiencing unsheltered homelessness, connect them with shelter, housing, or critical services, and provide urgent, non-facility based care to those unable to access shelter, housing, or an appropriate health facility. Only persons residing on the streets should be entered into a Street Outreach project. Projects assisting persons other than unsheltered persons must have two separate projects, one “Street Outreach” and one “Services Only”. Services Only (SSO): A project that offers Housing-structure specific OR Stand-alone supportive services (other than Street Outreach and Coordinated Entry) to address the special needs of participants. Day Shelter (DS): A project that offers daytime facilities and services (no lodging) for people experiencing homelessness. Other (OT): A project that offers services, but does not provide lodging, and cannot otherwise be categorized as another 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. Operating Start Date:* HMIS Participating Project (project enters data into HMIS):* YesNo 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 OnlyDS - Day ServiceOT - Other Note: If you are requesting a Joint TH-RRH Project Type, please note that these are required to be set up as separate projects in HMIS. We require a completed Project Request Form for each component, one for TH and one for RRH. 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. HUD Standards Information – Housing Projects Only (For each item, select only one option) Housing Type:* Site-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:* Entry/Exit DateNight-by-night Bed and Unit Inventory (ES/TH/RRH/PSH Projects only) Bed Inventory Household Type:* ------Households without childrenHouseholds with at least one adult and one childHouseholds with only children Bed Type (Facility-based or Voucher):* ------Facility basedVoucher Overflow Availability (Year-round, Seasonal or Overflow):* ------Year roundSeasonalOverflow Total Bed Inventory:* Total Unit Inventory:* Bed Inventory Start Date:* 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:* 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. If you already have a list of services provided in a file select "Yes" and attach them in the field below. If not please select "No" enter the list of services in the Project Services field below.* YesNo Enter all services provided for the PROJECT, not the entire agency. Project Services:* 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? Version 3.0 Last Updated 8/1/23
