Appendix F: Project Information Form

NYC HMIS

One form must be completed for each participating project.

Organization Name / Click here to enter text. /
Project Name (as per NYC HMIS) / Click here to enter text. /
Project Name (as per Grant) / Click here to enter text. /

Does this project serve or provide resource & referral services to clients?

Yes

No (skip to question #10)

  1. Project Type: (check ONLY ONE - Each project type is distinct and requires separate HMIS set-up. A project that has multiple types should complete multiple forms and only select one type per form/set-up. If you have more than one project type at your site (e.g. HUD TH and SAMHSA PATH), you must create separate projects in HMIS and upload for each project.)

Emergency Shelter / Safe Haven
Transitional Housing / PH - Housing Only
PH - Permanent Supportive Housing
(disability required for entry) / PH – Housing with Services
(no disability required for entry)
Street Outreach / Day Shelter
RETIRED / Homelessness Prevention
Services Only / PH – Rapid-Re-Housing
Other / Coordinated Assessment
  1. Method for Tracking Emergency Shelter Utilization: (check ONLY ONE)

Entry/ Exit Method

Night-by-Night Method

Not Applicable (Project Type is not an Emergency Shelter)

  1. Federal Partner Funding Source: (check all that apply and complete columns to the right)

Federal Partner Programs & Components / Grant Start DateMM/DD/YYYY / Grant End Date
MM/DD/YYYY
HUD:CoC – Homelessness Prevention (High Performing Comm. Only) / Enter Date / Enter Date /
HUD:CoC – Permanent Supportive Housing / Enter Date / Enter Date /
HUD:CoC – Rapid Re-Housing / Enter Date / Enter Date /
HUD:CoC – Supportive Services Only / Enter Date / Enter Date /
HUD:CoC – Transitional Housing / Enter Date / Enter Date /
HUD:CoC – Safe Haven / Enter Date / Enter Date /
HUD:CoC – Single Room Occupancy (SRO) / Enter Date / Enter Date /
HUD:ESG – Emergency Shelter (operating and/or essential services) / Enter Date / Enter Date /
HUD:ESG – Homelessness Prevention / Enter Date / Enter Date /
HUD:ESG – Rapid Rehousing / Enter Date / Enter Date /
HUD:ESG – Street Outreach / Enter Date / Enter Date /
HUD:Rural Housing Stability Assistance Program / Enter Date / Enter Date /
HUD:HOPWA – Hotel/Motel Vouchers / Enter Date / Enter Date /
HUD:HOPWA – Housing Information / Enter Date / Enter Date /
HUD:HOPWA – Permanent Housing / Enter Date / Enter Date /
HUD:HOPWA – Permanent Housing Placement (facility based or TBRA) / Enter Date / Enter Date /
HUD:HOPWA – Short-Term Rent, Mortgage, Utility assistance / Enter Date / Enter Date /
HUD:HOPWA – Short-Term Supportive Facility / Enter Date / Enter Date /
HUD:HOPWA – Transitional Housing (facility based or TBRA) / Enter Date / Enter Date /
HUD:HUD/VASH / Enter Date / Enter Date /
HHS:PATH – Street Outreach & Supportive Services Only / Enter Date / Enter Date /
HHS:RHY – Basic Center Program (prevention and shelter) / Enter Date / Enter Date /
HHS:RHY – Maternity Group Home for Pregnant and Parenting Youth / Enter Date / Enter Date /
HHS:RHY – Transitional Living Program / Enter Date / Enter Date /
HHS:RHY – Street Outreach Project / Enter Date / Enter Date /
HHS:RHY – Demonstration Project** / Enter Date / Enter Date /
VA: Community Contract Emergency Housing / Enter Date / Enter Date /
VA: Community Contract Residential Treatment Program*** / Enter Date / Enter Date /
VA:Domiciliary Care*** / Enter Date / Enter Date /
VA:Community Contract Safe Haven Program*** / Enter Date / Enter Date /
VA:Grant and Per Diem Program / Enter Date / Enter Date /
VA:Compensated Work Therapy Transitional Residence*** / Enter Date / Enter Date /
VA:Supportive Services for Veteran Families / Enter Date / Enter Date /
N/A / Enter Date / Enter Date /
* HUD:CoC – Coordinated Assessment – has been added as a placeholder for future guidance on Coordinated Assessment by HUD;
** HHS:RHY – Demonstration Project – It is the present intention of FYSB that any demonstration projects under RHY will be required to utilize HMIS in data collection. The demonstration project has therefore been included as a placeholder.
***VA programs not required to enter data into an HMIS except for Project Descriptor Data Elements in CoC’s where HMIS is generating the HIC.
  1. Bed and Unit Inventory Information:

Households without children / Households with at least one adult and one child / Households with only children
UNIT Inventory
BED Inventory
Of the BEDS shown above, how many are HMIS Participating Beds?
Of the BEDS shown above, how many are dedicated to the Chronically Homeless Bed Inventory (PSH Only)?
Of the BEDS shown above, how many are dedicated to Veteran Bed Inventory?
Of the BEDS shown above, how many are dedicated to Youth Bed Inventory?
Of the Youth Beds, what number are restricted to:
Only Under Age 18
Only Ages 18 to 24
Only Youth under age 24 (both of the above)
Emergency Shelters only: BEDS that are available on a Year-round basis?
Emergency Shelters only: BEDS that are available on a Seasonal basis?
Emergency Shelters only: BEDS that are available on an Overflow basis?
Emergency Shelters only: BED Type (insert number)?
Facility-based
Voucher
Other
  1. Main Site Address for the site where most of this project’s housing units are located or services are provided. If the project is mobile or scattered-site, provide the address of the administrative office for the project (DO NOT complete if this is a victim service project)

Street: Click here to enter text.

City:Click here to enter text.State: N.Y Zip Code: County:Click here to enter text.

  1. How would you describe the site where your housing units are located or your service encounters are provided? (check only one)

Multiple Sites

Single site, single building

Single site, multiple buildings

  1. Which of the following best describes the type of housing offered by this project at the main site?(check only one)

Emergency Shelter

Transitional Housing

PH - Permanent Supportive Housing

Safe Haven

PH - Housing Only

PH - Housing With Services

PH - Rapid Re-Housing

  1. Which of the following best describes the Funder: Program of housing offered by this project at the main site?(check only one)

HUD: CoC
HUD: ESG
HUD: HOPWA
HUD: HUD/VASH
HUD: RHSAP / HHS RHY
HHS: PATH
VA: HCHV
VA: GPD
VA: SSVF
  1. Which of the following best describes this residential project? (check only one)

Residential housing in a building or complex that houses populations with special needs (homeless or formerly people, people with substance abuse problems, people with mental illness, people with HIV/AIDS) AND people without any special needs / Residential housing in a building or complex that houses ONLY people with special needs (homeless or formerly people, people with substance abuse problems, people with mental illness, people with HIV/AIDS)
  1. Does this project have any of the following “target populations”? (if applicable, check only one – A population is considered a target population if the project is designed to serve that population and at least three-fourths of the clients served by the project fit the description.)

Domestic violence victims / People with HIV/AIDS
Veterans / Not Applicable
  1. When did your organization start operating this project (month/day/year)?