Santa Clara County HMIS New Program Request (2019-2020)
Please complete the following questions to set up your new program in HMIS. Once you submit this request, Bitfocus staff will follow up with you regarding any further questions and/or to confirm setup.
Email address *
Requester's Name *
Please list a person whom Bitfocus may contact to gather more information, if it is needed.
Your answer
Q1) Agency Name *
Your answer
Q2) Program Name *
Your answer
Q3) Grant Identifier
Your answer
Q4) Federal Funding Source *
If no Federal Funding Source, select "N/A" or "Local or Other Funding Source"
Q5) Program Type *
Q6) Street Address
Physical Location of Program or Administering Agency
Your answer
Q7) Operating Start Date *
This is the earliest date that clients can be enrolled into the program, which may be sometime before the program is actually set up in HMIS depending on the timing and nature of your request.
MM
/
DD
/
YYYY
Q8) Operating End Date
Optional. Leave blank if program is not time limited.
MM
/
DD
/
YYYY
Q10) Target Population *
Q11) Housing Type *
Required for Shelter/Housing projects
Q12) Geocode *
Please choose the city where the program is located. If the city is not listed, please choose "069085 - Other Santa Clara County"
Q13) Program Description *
Your answer
Q14) HMIS Participating Project *
(Optional) Responsible Staff Members
Optional. This person will receive email notifications from Clarity Human Services regarding clients referred to and/or enrolled in this program.
Your answer
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