HMIS DATA REQUEST FORM
Requester's Name *
Your answer
Requester's Organization *
Your answer
E-mail Address *
Your answer
Phone Number *
Your answer
Date of Request *
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YYYY
Desired Completion Date *
MM
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YYYY
1. Description of the Report/Data request *
Your answer
2. Purpose of the Report/Data request *
Your answer
3. Please explain how your request for report/data will potentially end homelessness in Chicago.
Your answer
Report Period Start Date (e.g. 01/01/2015) *
Your answer
Report Period End Date (e.g. 12/31/2015) *
Your answer
4. What universe of clients should be included? Please be as specific as possible (e.g. "Women age 18-34 enrolled in United Way Supportive Housing Program," "All clients enrolled in emergency shelters throughout Chicago" *
Your answer
5. Please choose which option best describes your agency. *
6. Please select the frequency of this report. *
7. How would you like to receive the report/data? *
8. If conducting a research study, list the key researcher(s) and their title(s)
Your answer
9. If conducting a research study, state whether you are pursuing IRB approval and the current status of your IRB submission (if applicable).
Your answer
10. Do you currently have funding or a grant for this request? List the top 5 resources? (There is an estimated cost of $125/hr for report requests.) *
Your answer
11. If no, are you currently seeking funding sources for this study?
Other Comments or Questions regarding this request?
Your answer
Thank You
Requests for HMIS data must be submitted to All Chicago utilizing this form. At the discretion of All Chicago, requests may be forwarded to a Data Advisory Committee for review and approval. There is an estimated cost of $125/hr for report requests. A Statement of Work outlining details may be requested by All Chicago if approved.

If using a paper version of this form, please email it to hmis@allchicago.org with the subject line "Report/Data Request" or fax request to 312-379-0304.

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