Please complete the form below. Report delivery times will vary depending on priority requests and other outstanding projects. Report requests must be submitted at least a week before they are needed.

Basic Information

Name

First Name

Last Name

Agency

Phone Number

(###)

###

####

Email Address

Taskforce/Workgroup

Does your agency currently use the Omaha/Council Bluffs HMIS?

Requested Report Delivery Date

YYYY

Report Details

Is the data request for a specific grant?

If the request is for data that will be used to complete a grant application, you must send a copy of the application to brandy.yant@icalliances.org with the title 'Grant Application to Accompany Custom Data Request.'

Grant application due date (if applicable)

YYYY

What will this report be used for?

Please provide specific details.

Which HMIS Provider(s) should be included in the report?

Please provide as much of the following as possible: Provider Name, Provider ID Number, Program Name (if applicable), ServicePoint workflow type (Entry/exit, Service Transaction, or Shelter Stays)

Data elements or assessment questions to include:

Would you prefer we count individuals and/or households?

What do you want the report to list?

Report Start Date

YYYY

Report End Date

YYYY

Provide any additional details that need to be included on the report

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