Homeless Management Information System (HMIS) New Agency Application

The Homeless Action Network of Detroit (HAND) oversees and manages our community’s Homeless Management Information System (HMIS), which is a web-based database used by service organizations to collect and record information on the people they serve. This information is collected for people who are experiencing homelessness and at-risk of homelessness.

The HMIS software allows for multi-level client data sharing between organizations, as well as client case coordination and electronic referrals. ** This sharing capability can prevent service duplications and enable collaboration between various homeless providers. Having access to HMIS represents a strategic advantage for your agency. Providers can utilize HMIS to evaluate program performance, provide better case management and coordination, and demonstrate program outcomes.

**NOTE: Out of a concern for protecting client privacy, the visibility of existing client data and service transactions is limited to agencies that the client and our continuum have agreed to share data with. New agencies will only see data going forward from the point they join the system.

BASIC INFORMATION

Why is this agency/program seeking HMIS participation?
Click + enter text.

The minimum requirements for HMIS are:

Memory	Monitor
4 Gig recommended, (2 Gig minimum)	Screen Display - 1024 by
768 XGA)
Processor	Internet Connection
A Dual-Core processor is recommended.	Broadband

Browser

Firefox 3+ is recommended ESV version Internet Explorer 8+ is supported.
Other browsers work with varying results.

Does the agency meet the minimum equipment requirements (hardware and software)? Click & Choose

Is the agency an active member of the Continuum of Care (missed less than 25% of the meetings in the last calendar year)? Click & Choose

For each program being considered for HMIS access, complete questions 4-15 and all questions under the “SERVICES” and “ELIGIBILITY” sections. Use additional pages if necessary and attach.

Specific Program Information:
Organization Name: Click + enter text.
Specific Program Name: Click or tap here to enter text.
Address: Click + enter text.
Address 2: Click + enter text.
City: Click or tap here to enter text. State: Click or tap here to enter text. Zip: Click + enter text.
Office Phone Number: Click + enter text.
Source of Program Funding: Click + enter text.

Contact 1 (for program above):
Who is the person that oversees or is responsible for the program listed above?
Name: Click + enter text.
Title: Click + enter text.
Email Address: Click + enter text.
Phone Number: Click + enter text.

Contact 2 (for the program above):
Name: Click + enter text.
Title: Click + enter text.
Email Address: Click + enter text.
Phone Number: Click + enter text.

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Hours of operation (for program above, please be specific):Click + enter text.

Describe your intake/admission process (example: Call in Fridays 9-12N,
No Walk-ins, etc…): Click + enter text.

Do you have a current intake form? Click & Choose If yes, please provide a copy. Please describe in detail the collected elements, if no copy is available. Click + enter text.

Do you currently conduct exit interviews? Click & Choose

Do you document program eligibility? Click & Choose

Is your program location handicap accessible? Click & Choose If yes, please describe specific accommodations (i.e., 2 rooms with modifications, elevator, ramp, etc):

Click + enter text.

How many clients did the agency serve in each of the following categories?

Click + enter text. Homeless Click + enter text. At risk of homelessness

Which homeless sub populations (if any) does this specific program serve? (Check all that apply)

☐Single Adult Males ☐Single Adult Females ☐Households w/o Children
☐Single Males w/Children ☐Single Females w/Children ☐Households w/Children
☒Unaccompanied Male Minors ☐Unaccompanied Female Minors
☐Victims of Domestic Violence ☐Persons with HIV/AIDS

Please check the “Housing Type” or configuration in which participants under this program are housed:

3 (Residential Programs Only)
☐Mass Shelter/barracks

☐Dormitory/Hotel/Motel

☐Shared Housing

☐Single Room Occupancy (SRO) Units

☐Single Apartment Single Homes/Townhouses/Duplexes (Non-SRO) Units
☐N/A

SERVICES

Please answer all questions below related to the services you are rendering in relationship to the specific program from Page Two.

What PRIMARY SERVICES does this program provide? (Check all that apply)
Primary Services are direct services you provide NOT services you refer clients to.

☒Utility Bill Payment Assistance

☐Rent Payment Assistance

☐Legal Services

☐Emergency shelter

☐Street Outreach Programs

☐Transitional Housing/Shelter

☐Supportive Housing Placement

☐Housing Search Assistance

☐Transportation

☐Information and Referral

☐Temporary Mailing Address

☐Clothing

☐Identification Card(s)

☐Sack Lunches

☐Alcohol & Drug Abuse Treatment

☐Child Care

☐Counseling/Advocacy

☐Education

☐Employment

☐Health Care

☐HIV/AIDS Assistance

☐Mental health

☐Not Applicable (N/A)

☐ Other:

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ELIGIBILITY

1. Please describe eligibility requirements for this program. Click + enter text.
2. Do you document program eligibility? Click & Choose If not, would you be willing to do so going forward? Click & Choose

3.	Is this program dedicated to serving the homeless population or can it serve both the homeless and non-homeless? Click & Choose.

4.	How is homelessness defined for the program? Click + enter text.

5.	Must a person be at or below a certain income level to be eligible for this program?Click & Choose
If yes, what is the criteria? Click + enter text.

6.	Must a person have a source of income to be eligible for this program? Click & Choose
If yes, will your program waive the requirement on a case by case basis if a person has no income but is otherwise eligible for the program? Click & Choose

7.	Does this program charge program fees? Click & Choose
If yes, describe the fees including if your program will waive fees if a person is unable to pay. Click + enter text.

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