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1. Intake Forms

1.1. HMIS Forms for Balance of State and Mahoning CoCs

The forms available on this page have been created by COHHIO for use by the Balance of State CoC and the Mahoning CoC. They were based on the terrific forms that were created by Region 5 in 2015 when HUD last modified the data standards and parts are from a draft of the forms in Toledo! Thanks to everyone who has shared their forms and made them available to others.

THESE FORMS ARE NOT "FILLABLE" FORMS. They are meant to be printed and filled in by hand so that an HMIS user can enter the data within 5 days of the intake/update/exit.

The forms here are in Word format (not .pdf) so that they can be modified if necessary, however, to our knowledge, everything that is required by HUD and the state to be collected is already on the forms. If anyone notices anything that is missing or off, please send an email to the help desk!

Please note there are three different intake forms:

  1. Initial Intake: there are separate ones for SSVF projects; Emergency Shelter or Safe Havens; PSH, HP, or RRH projects; and TH projects.
  2. Update: (required for projects that ever house people for longer than a year)
  3. Exit: All projects will use this.

So far, we do not have RHY, PATH, or HOPWA forms ready, so we suggest using your current forms plus maybe the Residence Prior page of the forms offered here. You are free to use these forms to create what you need as well.



2018 HMIS Intake Form SSVF
7/13/2018 11a
2018 HMIS Intake Form ES SH 7/13/2018 11a
2018 HMIS Intake Form PSH HP RRH 7/13/2018 11a
2018 HMIS Intake Form TH
7/13/2018 11a
2018 HMIS Exit Form (universal)
7/13/2018 11a
2018 HMIS Update Form (universal)
7/13/2018 11a
2018 Unsheltered Form (BoS Only!)
7/13/2018 11a

2. Client Notification and Consent Forms

2.1. Client Notification and Consent Forms

This for only a template. You will need to modify the language to fit your facility. The attached file contains three documents:

1. Ohio BoSCoC's HMIS Data Privacy Notice & Consent. All clients (except RHY and SSVF) MUST sign this form before their PII is entered into HMIS.

2. Ohio BoSCoC's HMIS Release of Information. All clients (except RHY and HOPWA) MUST sign this form for their record to remain unlocked in HMIS.

3. Ohio BoSCoC's HMIS Posted Data Privacy Notice. All agencies entering data into HMIS are required to have this notice visibly posted in the areas where client data is collected.

2.2. List of Active Agencies in ServicePoint

Upon request, any client can be provided with a list of agencies who share data in ServicePoint (attached). Please note that this list is only updated annually. Any questions about this list may be directed hmis@cohhio.org .

Last updated: 01/09/2018

3. New Project Form

3.1. New Project Form

This form is also located in ART: Public Folder > Balance of State > As Needed and Custom Reports > Housing Inventory > New Project Form.

4. HMIS Diversion Form and Screening Script

4.1. HMIS Diversion Form and Screening Script

his form should be used when you are unable to complete HMIS data entry real time for Diversion. This data collection should occur after the client provides verbal (by phone) or written consent to data collection and before you have the diversion conversation with the client using the Diversion Screening Script.

HMIS Diversion Form

Diversion Screening Script

5. Resources

5.1. List of HMIS Resources

HMIS Resources

Matt Dicks
(614) 280-1984 ext. 120
Genelle Denzin
(614) 280-1984 ext. 123
Amanda Wilson
(614) 280-1984 ext. 115

Ohio Balance of State HMIS login page: https://sp5.servicept.com/odod
Youngstown HMIS login page: https://sp5.servicept.com/youngstown
Help Desk Portal (Website): http://hmis.cohhio.org/
Help Desk Email: hmis at cohhio dot org

Ohio Balance of State HMIS Policy and Procedures Manual: http://hmis.cohhio.org/index.php?pg=kb.page&id=38
Ohio Balance of State HMIS Data Quality Standards: http://hmis.cohhio.org/index.php?pg=kb.page&id=39

COHHIO: http://www.cohhio.org/
Ohio Balance of State's HMIS Lead = COHHIO
Youngstown's HMIS Lead = Catholic Charities Regional Agency

HUD: https://www.hudexchange.info/
HUD’s websites about HMIS: https://www.hudexchange.info/hmis/ or http://www.hudhdx.info/ or

VA’s website about HMIS (for SSVF programs): http://www.va.gov/HOMELESS/HMIS.asp

Learn about VAWA: http://en.wikipedia.org/wiki/Violence_Against_Women_Act

National Alliance to End Homelessness: http://www.endhomelessness.org/