Orange County Continuum of Care – 2016 Request for Qualifications

EXHIBIT 3: Participation Status in Local Continuum of Care, Ten Year Plan to End Homelessness, and HMIS Data Information

Agency Name:

Ten Year Plan to End Homelessness andLocal Continuum of Care (CoC) Participation

The level of agency participation at the local CoC and 10 Year Plan to End Homelessness implementation group committees, subcommittees, and/or working groups will be considered in theRequest for Qualifications evaluation process.

Homeless Management Information System (HMIS) Data Information

It is critical that programs in the Continuum of Care submit timely, complete, and accurate data to HMIS. To assist in CoC evaluation of performance measures on a program and systems-wide level.

  1. Does your agency currently participate in the Orange County CoC HMIS (Adsystech) or comparable database that complies with HUD’s HMIS requirements if your agency is a victim services provider?

☐Yes ☐No

  1. If your agency does not participate in the Orange County CoC HMIS, please indicate why?
  1. If your agency does participate in the Orange County CoC HMIS, please provide the contact information of your Agency HMIS Administrator below.

Name:
Title:
Phone:
Email:
  1. Does your agency currently participate in another Continuum of Care HMIS or comparable database that complies with HUD’s HMIS requirements if your agency is a victim services provider?

☐Yes ☐No

  1. If you agency does participate in another Continuum of Care HMIS or comparable database, indicate the Continuum of Care and the HMIS or comparable database vendor.

Continuum of Care / HMIS or Comparable Database Vendor

2016 Annual Sheltered Homeless Count

  1. Did your agency participate in the 2016 homeless count for the Orange County Continuum of Care?

☐Yes ☐No

  1. If applicable, did your agency submit the complete and accurate information requested for the homeless count by the deadline?

☐Yes ☐No

  1. If no, why did your agency not meet the required deadline?

2016 Annual Housing Inventory Count

  1. Did your agency submit the complete and accurate information requested for the Housing Inventory Count for Orange County Continuum of Care by the deadline?

☐Yes ☐No

  1. If no, why did your organization not meet the required deadline?

Name, Title and Signature of Person who will complete the application:

Name/TitleSignatureDate

Name and Signature of Person authorized to sign the HUD application:

Name/TitleSignatureDate

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