Project Request Form

Agency Information
Agency Name
Project Name
Provider Project Description:

Describe the primary function/services provided by this project.

Note: Do not describe the entire agency function, just the function of this project.
Description
Project Location:
Address

Street Address

County

CityState

Zip Code
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

First NameLast Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is there a secondary liaison?
Secondary Liaison?
Secondary Name

First NameLast Name
Secondary Title
Secondary Email
example@example.com
Secondary Phone Number
Please enter a valid phone number.
Project Type Descriptions:

•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 Re-Housing ( 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): 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.
Operating Start Date

MonthDayYear
Date
HMIS Participating Project (project enters data into HMIS)

YesNo
HMIS Participating2
Project Type (select one option)

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.
Projects:

ES Emergency ShelterTH Transitional HousingRRH Rapid rehousingPSH Permanent Supportive HousingPH Housing OnlyPH Housing with ServicesHP Homeless PreventionSO Street OutreachSSO Services OnlyDS Day ShelterOT Other
Type of Project (your choice from above)
Related Program
Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
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”
Housing

Site-based-single siteSite-based-clustered/multiple sitesTenant-based-scattered siteNA
Housing Type2
Target Population

Check "NA" unless your project specifically is funded for one of the other choices
Population

Survivors of Domestic ViolencePersons with HIV / AIDSNA
Target Population2
Household Type

Households without childrenHouseholds with only childrenHouseholds with at least one adult and one child
Household Type2
Bed Type

Facility-basedVoucher
Bed Type2
Overflow Availability

Year-roundSeasonalOverflow
Overflow2
Bed and Unit Inventory (ES / TH / RRH / PSH Projects only)

* Required Field
Total Bed Inventory
Total Unit Inventory
Bed Inventory Start Date

MonthDayYear
Date
Youth Veteran Beds
Other Veteran Beds
Non-Dedicated Beds
Other Youth Beds
Any Other Chronic Beds (PSH Only)
Chronic Homeless Youth Beds (PSH Only)
Chronic Homeless Veteran Beds (PSH Only)
Services Provided

Instructions: Fill in the table below, based on the details described.

Please use service terms given in your contract if applicable, for services to be provided to clients. If you already have a list of services provided in a file select “Yes” and upload your document by using the upload document button at the bottom of this webpage.

If not, please select “No”, and enter all services in the field below.
Are services provided?

YesNo
Services Provided2
Project Services:
Enter all services provided for the PROJECT, not the entire agency
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
Access to contract2
If applicable, what are the reporting deliverables for your contract?
Reporting requirements (Provide contract page(s) showing requirements by uploading document at the bottom of this webpage.)
Funding Agency / Jurisdiction
List funding source agency / jurisdiction
Contract Administrator at Funding Agency / Jurisdiction
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Contract period start date:

MonthDayYear
Date
Contract period end date:

MonthDayYear
Date
Are the costs for new HMIS licenses included in the contract? If unsure check NO

YesNo
Costs for new HMIS licenses2
If HMIS licenses included, how many users?
Additional Comments?
Please verify that you are human*
File Upload

Cancelof
Should be Empty:

Agency Information

Project Location:

Project Type (select one option)

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

Profile – Project Funding & Reporting Requirements

Contract Administrator at Funding Agency / Jurisdiction