HMIS License Request Form

HMIS License Request Form

Please complete the following form to request a new license or transfer a license. If requesting multiple licenses, please complete a separate form for each license.
Agency
Name of Supervisor
Supervisor Email
example@example.com
What type of License Request do you have?
By Selecting "Purchasing a New License," do you understand that an invoice/bill will follow this submission?

YesNo
If "Yes" to the above, please indicate who is approving this purchase:

First NameLast Name
If inactivating, do you plan to keep this license to assign to a new person?

YesNo
Name of Person to Inactivate:

First NameLast Name
Date the person left/is leaving the agency:

MonthDayYear
Date
Name of Existing Licensee:

First NameLast Name
Name of New Licensee:

First NameLast Name
New Licensee Email:
example@example.com
New Licensee Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Does the new licensee have any HMIS experience (with ServicePoint specifically)?

YesNo
Will this user be responsible for submitting monthly APRs as a part of the CoC's Data Quality Plan?

YesNoI don't know what this is
Please tell us what the new licensee will be doing.
**This will help guide their training**
Will they be entering data for the CoCs Coordinated Entry project?

YesNo
Will they need any Counts Reports set up on their Home Page Dashboard?

YesNoI Don't Know What This Is
Will they be responsible for answering any incoming referrals through HMIS?

YesNoI Don't Know What This Is
Will they be responsible for recoding any Service Transactions?

YesNoI Don't Know What This Is
Will this licensee need access to the SAP Business Objects (formerly named ART) tool?

YesNo
Please list the HMIS project(s) they will be entering data into:
Please provide the Continuum of Care (CoC) Code for your Agency’s service area:*

VA-501 (Norfolk, Chesapeake, Suffolk, Franklin, Isle of Wight County, and Southampton County)VA-505 (Newport News, Hampton, Poquoson, Williamsburg, James City County, and York County)VA-503 (Virginia Beach Continuum of Care)VA-507 (Portsmouth Homeless Action Consortium)VA-508 (City of Lynchburg and the Counties of Amherst, Appomattox, Bedford and Campbell)Not Sure Which One
SCHEDULING TRAINING
Preferred training date:

MonthDayYear
Virtual Training is available every Thursday at 9AM. Please indicate the upcoming training date the new licensee plans to attend. We will be in touch to provide you with training registration info.
Notes
NOTICE: ALL NEW LICENSEES MUST BE TRAINED BY A SYSTEM ADMINISTRATOR AND SIGN A NEW USER AGREEMENT. NEW AGENCIES MUST ALSO 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.
Should be Empty:

HMIS License Request Form

SCHEDULING TRAINING