211OC HMIS Report Request Form

211OC HMIS Report Request Form

Agency Name:

Requested By:

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Date of Request:

Email:

/

Phone #:

Description of request:

Report Start Date:

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Report End Date:

What population of clients should be included on the report? (Please choose only one)

 / Clients served in Orange County (if the report is for clients in Orange County, only aggregate reports can be provided) /  / Clients served at my agency only

Which projects should be included on the report?

 / All projects
 / Only these project types (Select all that apply)
 / Emergency Shelter /  / Other /  / Day Shelter
 / Transitional Housing /  / PH - Permanent Supportive Housing (disability required for entry) /  / Homelessness Prevention
 / Safe Haven /  / PH – Housing Only /  / PH - Rapid Re-Housing
 / Street Outreach /  / PH – Housing with Services (no disability required for entry) /  / Coordinated Assessment
 / Services Only
 / Specific projects (please list)

Which clients should be included on the report? (Please choose only one)

 / Active clients (any enrollments during the reporting period) /  / Exited clients (enrollments with project exit dates during the reporting period)
 / New clients (enrollments with project entry dates during the reporting period) /  / Any services provided during the reporting period

Which fields should be included on the report? (Ex. First name, last name, gender, race, etc.)

1 / 6 / 11
2 / 7 / 12
3 / 8 / 13
4 / 9 / 14
5 / 10 / 15

When should the report be completed by? (Must be at least 3 days after date of request)

Please send completed form to sed 8/31/15