Santa Clara County HMIS New Program Request

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Please complete the following questions to set up your new program in HMIS (this should be filled in by the Agency Lead). Once you submit this request, Bitfocus staff will follow up with you regarding any further questions and/or to confirm setup.

Email *

Agency Name *

The agency that will be administering this program.

Requester's Name (Agency Lead/Admin.) *

Please list a person whom Bitfocus may contact to gather more information, if it is needed.

Program Name *

Program Description *

A brief description of the program and types of services provided.

Operating Start Date *

This is the date clients are expected to be enrolled into the program. The Operating Date should not lapse more than one (1) day from time of actual enrollment.

YYYY

Operating End Date

When will this program stop providing services. Leave blank if program is not time limited.

YYYY

Program Address

Physical Location of Primary Program Site. If there is no program site, enter the administrative address, please be sure and include zip code.

Q12) Geocode *

Please choose the city where the program is will operate. If the city is not listed, please choose "069085 - Other Santa Clara County"

Q14) HMIS Participating Project *

Will this project enter client information into HMIS. (this is usually YES)

(Optional) Responsible Staff Members

Optional. Responsible Staff Members- Enter the name and email address for one or more HMIS users at your agency to receive email notifications from Clarity Human Services regarding clients referred to and/or enrolled in this program.

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