Technical Assistance (TA) Form
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Name
*
Please Select
ACCHH - Alachua County Coalition for the Hungry & Homeless
ACCSS - Alachua County Community Support Services
ACHA - Alachua County Housing Authority
Catholic Charities Gainesville
Catholic Charities Putnam
CDS, Family & Behavioral Health Services
Family Promise Gainesville
GHA - Gainesville Housing Authority
Meridian Behavioral Healthcare
NHDC - Neighborhood Housing & Development
PCSC - Heart of Putnam Service Center
SFH - St. Francis House
Block by Block
The Veteran Administration of Gainesville
Volunteers of America GPD Programs
Volunteers of America SSVF Programs
Other
If Other Specify Below
Name The Other Agency Name
Date of TA Request
*
-
Month
-
Day
Year
Date
TA Request Urgency Level
*
Please Select
Low (Informational or Routine)
Medium (Needs Resolution This Week)
High (Affecting Project Operations/ Report Deadlines)
Critical (Access Breach, System Failure, Client Impact)
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Request Category
*
Please Select
User Account & Access
Project & Agency Request
Reporting Assistance
Data Quality Support
Technical/ System Issues
Privacy & Security
Training & Resource Requests
Miscellaneous
Other
If Other Please Enter Here
User Account & Access
Create User Account
User Deactivation Request
User Reactivation Request
Login/Access Issues
Password Reset
Add Project Access To User Account
Remove Project Access From User Account
Edit User Permissions - (Change Roles/ Permissions)
Other
New User Information
Please complete all fields or new user will not be created.
User Full Name
First Name
Last Name
User Email
example@example.com
User Role
Needs HMIS Basic Training?
Please Select
Yes
No
Project & Agency Requests
New Project Setup
Project Update - Funding Source
Project Update - Bed & Unit Inventory
Project Update - CE
Project Update - Any Other
Close/ End Project
Add Additional Site - (Ex. A shelter with a different location than agency address)
Other
Program Setup
Program Name
*
Program Description
*
HMIS Service Type
*
Please Select
HUD CoC (Standard)
PATH
RHY
SSVF
VA Grant
GPD
Other
Operating Start Date
*
-
Month
-
Day
Year
Date
Operating End Date
-
Month
-
Day
Year
Date
Funding Source Name
*
Funding Source
*
Please Select
HUD: CoC – Homelessness Prevention (High Performing Comm. Only)
HUD: CoC – Permanent Supportive Housing
HUD: CoC – Rapid Re-Housing
HUD: CoC – Supportive Services Only
HUD: CoC – Transitional Housing
HUD: CoC – Safe Haven
HUD: CoC – Single Room Occupancy (SRO)
HUD: CoC – Youth Homeless Demonstration Program (YHDP)
HUD: CoC – Joint Component TH/RRH
HUD: ESG – Emergency Shelter (operating and/or essential services)
HUD: ESG – Homelessness Prevention
HUD: ESG – Rapid Re-Housing
HUD: ESG – Street Outreach
HUD: ESG-CV
HUD: ESG-RUSH
HUD: Unsheltered Special NOFO
HUD: Rural Special NOFO
HUD: Pay for Success
HUD: Public and Indian Housing (PIH) Programs
HUD: HOPWA – Hotel/Motel Vouchers
HUD: HOPWA – Housing Information
HUD: HOPWA – Permanent Housing (facility based or TBRA)
HUD: HOPWA – Permanent Housing Placement
HUD: HOPWA – Short-Term Rent, Mortgage, Utility assistance
HUD: HOPWA – Short-Term Supportive Facility
HUD: HOPWA – Transitional Housing (facility based or TBRA)
HUD: HOPWA-CV
HUD: HUD/VASH
HUD: PIH (Emergency Housing Voucher)
HUD: HOME
HUD: HOME (ARP)
HHS: PATH – Street Outreach & Supportive Services Only
HHS: RHY – Basic Center Program (prevention and shelter)
HHS: RHY – Maternity Group Home for Pregnant and Parenting Youth
HHS: RHY – Transitional Living Program
HHS: RHY – Street Outreach Project
HHS: RHY – Demonstration Project
VA: CRS Contract Residential Services
VA: Grant Per Diem – Bridge Housing
VA: Grant Per Diem – Low Demand
VA: Grant Per Diem – Hospital to Housing
VA: Grant Per Diem – Clinical Treatment
VA: Grant Per Diem – Service Intensive Transitional Housing
VA: Grant Per Diem – Transition in Place
VA: Grant per Diem – Case Management/Housing Retention
VA: Community Contract Safe Haven Program
VA: Supportive Services for Veteran Families
Local or Other Funding Source (Please Specify)
Enter Local or Other Funding Source Below
Funding Start Date
*
-
Month
-
Day
Year
Date
Funding End Date
-
Month
-
Day
Year
Not Required to start the program unless provided on your contract.
Grant Identifier
*
Grant/Funding identifier, Contract Number, or anything used to uniquely identify this funding source.
Grant Amount
Program Type
*
Please Select
Emergency Shelter - Entry Exit (ES)
Emergency Shelter - Night by Night (ES)
Day Shelter
Transitional Housing (TH)
Safe Haven (SH)
Permanent Supportive Housing (PSH) (Disability Required For Entry)
Rapid Re-Housing (RRH)
Permanent Housing Only
Permanent Housing With Services (No Disability Required For Entry)
Coordinated Entry (CE)
Street Outreach (SO)
Services Only
Homelessness Prevention (HP)
Other
Continuum Project
*
Please Select
Yes
No
A Project that is part of a community's overall strategy to end homelessness.
Programs Location (If different from main office)
Target Population
*
Please Select
DV: Survivors of Domestic Violence
HIV: Persons with HIV/AIDS
NA: Not Applicable
Site Type
Please Select
Site Based: Single Site
Site Based: Clustered/Multiple Sites
Tenant Based: Scattered Site
Single Site - All project participants live or receive services at one physical location. Clustered/Multiple Sites - the project operates in multiple physical locations, but are managed as one single project. Scattered Site - private, individual units scattered across the community, not centralized at a single project site.
Geocode
*
HMIS Participation Status
*
Please Select
Not Participating
HMIS Participating
Comparable Database Participating
Project is a Coordinated Entry Access Point
*
Please Select
Yes
No
Provided by CE Project
*
Homelessness Prevention Assessment, Screening, and/or Referral
Shelter Assessment, Screening, and/or Referral
Housing Assessment, Screening, and/or Referral
Direct Services (search and/or placement support)
Program Receives CE Referrals?
*
Please Select
Yes
No
CE Participation Start Date
*
-
Month
-
Day
Year
Date
CE Participation End Date
-
Month
-
Day
Year
Date
HOPWA-Funded Medically Assisted Living Facility
*
Please Select
NA- Non HOPWA Funded
No
Yes
Bed & Unit Inventory - Emergency Shelter
Inventory Start Date
*
-
Month
-
Day
Year
Date
Inventory End Date
-
Month
-
Day
Year
Date
Household Type
*
Please Select
Households Without Children
Households With At Least One Adult And One Child
Households With Only Children
Bed Type
*
Please Select
Facility Based Beds
Voucher Beds
Other Beds
Availability
*
Please Select
Year-Round
Seasonal
Overflow
Youth Veterans
Any Other Veteran
Any Other Youth
Non-Dedicated Beds
Total Unit Inventory
*
Ex. How Many Rooms are the beds split into?
Do You Need To Configure Another
*
Please Select
No
Yes
For Programs with two different household types.
Inventory Start Date
*
-
Month
-
Day
Year
Date
Inventory End Date
-
Month
-
Day
Year
Date
Household Type
*
Please Select
Households Without Children
Households With At Least One Adult And One Child
Households With Only Children
Bed Type
*
Please Select
Facility Based Beds
Voucher Beds
Other Beds
Availability
*
Please Select
Youth Veterans
Any Other Veteran
Any Other Youth
Non-Dedicated Beds
Total Unit Inventory
*
Ex. How Many Rooms are the beds split into?
Reporting Assistance
Data Quality Framework Help
APR Setup or Correction Help
Caper Setup or Correction Help
Hashed HMIS & EVA Help
PIT/HIC Support
Custom Report Development
Create Reporting Group
Other
Data Quality Support
Data Quality Assistance (Help Resolving An Issue)
Data Quality Certification Assistance
EVA Tool Support (Cleaning & How To Use)
Data Quality Plan Questions
Duplicate Clients
Other
Technical/System Issues
System Error Messages
Data Not Saving/Loading
Page or Reporting Not Loading
Unexpected Behavior or Bugs
Other
Privacy & Security
Privacy Breach or Concern
Client Consent or ROI Questions
Reporting Misuse of Client Data
Client Request Deletion of HMIS Data
Other
Training & Resource Requests
Request for One-On-One Training
Request for Group Training
System Workflow Training
Policy/Procedure Clarification (Ex. UDE/PDE standards)
Other
Miscellaneous
General Question or Clarification
Suggestions for Improvements
Request Follow-up on Previous TA Request
Other
Enter A Brief Description of The Issue
*
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