HMIS Project Request Form

New HMIS Project & Update Request Form

Use this form to request a new project setup in the Partners In Care O'ahu HMIS, or to submit updates to an existing HMIS project.

New Project Requests

If your agency is not currently a participating member of Partners In Care and/or does not already have PIC HMIS Access, you must first submit a PIC Membership Form, submit the HMIS Access Request form, and receive approval from the PIC Data Committee before being granted HMIS access.

Agency Name

Agency Point of Contact

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Program Name

Program Name as it will appear in HMISProgram Alias or other name for project (if applicable)

Is this a new project request or a project update?

Type of Update Needed

Effective Date of Change

Date

Please detail other updates:

Program Closure Date

Date

Reason for Change?

Project Point of Contact

First NameLast Name

Project Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Point of Contact Email Address

Agency Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Project Address (if different than agency address)

Street Address

Street Address Line 2

City

Postal / Zip Code

Please provide a brief description of your program:

Tell us about this project, who it for, and what it does

Project Operating Start Date

Date

Project Operating End Date

Date

List staff members assigned to this project:

Project Type

Target Population

Project Site Type

Rapid Rehousing Subtype

Please check all funding sources for this program

If Local or Other Funding:

Grant Details

Grant Start Date

Date

Grant End Date

Date

How to report your inventory:

A bed = one sleeping spot for one person.
A unit = one "household spot" — a room, apartment, or home your project can put one household (of any size) into.

Example Projects	Beds	Units
Congregate/dorm shelter (shared room, cots or bunks)	Count every sleeping spot	Same as bed count, unless you have separate private rooms — then count the rooms
Family shelter with private rooms	Count total sleeping spots across all rooms	Count the number of private rooms
Scattered-site apartments (RRH, PSH)	If you know exact bedroom/bed capacity, add it up. If not: multiply number of units × estimated average household size	Count the number of apartments/leases you can support at once
Hotel/motel vouchers	The most guests you could house on any single night	The most rooms you could pay for on any single night
Projects with a fixed number of vouchers	Base both numbers on the number of vouchers to be funded and available	Same as beds

Inventory Start Date

Date

Inventory End Date

Date

Bed Type

Availability

Household Type

Please specify which types of households this project will provide beds / units for:

Number of units for Households without children

Number of units for Households with at least one adult and one child

Number of units for households with only children

Total Units

Please select which populations have dedicated beds for your project. If none of your beds are designated for these specific populations, select "Non-dedicated."

Chronically Homeless Veteran Beds

Youth-Veteran Beds

Other Veteran Beds

Chronically Homeless Youth Beds

Other Youth Beds

Other Chronically Homeless Beds

Non-Dedicated Beds

Total Beds

Community expectations are that Outreach Enrollments should have client activity logged at least once every 90 days. Clients without activity in 90 days will be auto-exited.

How many days can a client stay enrolled without any services added before the enrollment gets auto-exited ?

Please give your reasons for not wanting auto-exit for this outreach program:

How will this contract receive referrals into the program:

Other: explain referral /entry process

What is the ratio of CES to Community referrals (example: split 50/50)

List all program eligibility requirements as specified by funder (Examples: chronically homeless, minor children, etc) as well as any disqualifying factors (Examples: felony charges)

List all documents required to complete a housing placement

List all documents required to enroll in this program

What is the length of financial assistance this contract can provide each household? (Example: up to 3 payments of financial assistance, 1-3 months rental assistance to include utilities, 4-12 months)

What (if any) is the cap for the amount or length of rental assistance this contract can provide a household?

What is the participant's financial responsibility for the duration of enrollment? If there is a process for determining this, please explain:

What level of case management is provided with this program (including how often case management will meet with each household and for how long)?

How many case managers will be staffing this program and what will be their average case load?

Are there any target populations your program hopes to serve or have specified to serve in your contract?

What is the rate of placements needed per month and for how many months in order to meet contract requirements? (Example: Starting on May 1, 2027, program will place 10 households a month in permanent housing for a duration of 6 months in order to meet contract utilization requirements)

Will this program be tracking client services?

PLEASE NOTE - For ESG Street Outreach:

The following services will automatically be available and expected to be tracked in HMIS:

Engagement / initial assessment
Case management
Emergency health services
Emergency mental health services
Transportation

Any additional services to be tracked can be added below.

PLEASE NOTE - For ESG Emergency Shelters:

The following services will automatically be available and expected to be tracked in HMIS:

Case management
Child care
Education services
Employment assistance / job training
Outpatient health services
Legal services
Life skills training
Mental health services
Substance abuse treatment services
Transportation

Any additional services to be tracked can be added below.

PLEASE NOTE - For ESG Homelessness Prevention:

The following services will automatically be available and expected to be tracked in HMIS:

Housing search and placement
Housing stability case management
Mediation (e.g., landlord)
Legal services
Credit repairRental application fee assistance
Security deposit assistance
Last month's rent assistance
Utility deposit/payment assistance
Moving cost assistance
Short/medium-term rental assistance

Any additional services to be tracked can be added below.

For each service you will be asked to choose one of the following delivery types:

Single Event - This option allows the service date to be set as both the Start and End Date, streamlining data entry and preventing users from accidentally setting a future end date for a service associated with a single date.
Long Term – This option allows you to provide the service to an individual or household when it is provided. Use this option for services that are not provided every day.
Daily Attendance – This option allows you to add the service to a list of clients who will be provided with the service once per day. This service is ideal for tracking bed nights for Emergency Shelter projects.
Multiple Attendance – This option allows you to provide the same service to a list of clients multiple times per day

You will also be able to slect from the following options for each service:

Track Time - allows you to keep track of how much time you’ve spent on a service. Only available for case management/counseling type services.
Track Dollar Amount - allows you to enter a dollar amount for the service to track the amount of a gift card or rental assistance payment provided. Only available for financial type services.
Enable Geolocation - allows users to record geographic location information in a service item in a client record. That information is then displayed in an interactive map within the service item. Available for all services.

If you do not want any of these options applied to a service, simply leave the checkboxes blank.

Service List

Once the PIC Help Desk receives your request, a follow-up call will be scheduled.

Project Information

Project Update

New Project Request

Grant and Funding Information

Housing Inventory

Population Dedicated Beds

Rapid Rehousing Programs

Service Information