Agency/User HMIS Access Forms
Agency Partner Agreement
This form is an agreement between your agency and the Institute for Community Alliances (ICA), the HMIS Lead for the MoHMIS. The form describes our mutual responsibilities in connection with the use of the HMIS database. It spells out many of the duties of the partner agency as a whole toward maintaining the confidentiality of client information.
This form must be completed before the agency is provided with access to the database, and again each August. Complete the Agency Partner Agreement using the link below. It must be completed by the agency's Executive Director (or equivalent).
Note: This form is digital and you will be directed to DocuSign to complete the form. If you have any questions about completing the form, please contact the helpdesk.
User Access Request
On the User Access Request form, the Executive Director (or other authorized designee) indicates what project(s) each individual needs to be able to access, provides the individual's contact information, and a couple more details about the user's access to the HMIS. This is used by ICA System Administrators to follow up with the individual to complete the User Policy and Responsibilities form, as well as ensure the user has proper training to complete the data entry required.
This form is utilized to initiate training for new users, and must also be completed each August for each current user to maintain access. It must also be completed any time an individual's access rights to the HMIS should be modified (e.g., change in job responsibilities, transfer to a different department).
Note: This form is digital and you will be directed to Formstack to complete the form. If you have any questions about completing the form, please contact the helpdesk. Additionally, please note that all active users on HMIS must have their User Access Request renewed every August.
User Policy and Responsibilities
On this form, the end user agrees to follow all HMIS policies and responsibilities. This form must be completed before the user is provided with training and access to the system, and again each August to maintain access to the HMIS.
Note: This form is digital and you will be directed to Formstack to complete the form. Additionally, please note that all active users on HMIS must have their User Policy and Responsibilties renewed every August. If you have any questions about completing the form, please contact the helpdesk.
Agency Policy Forms
Privacy and Security Notice (Revised June 2011)
Client Informed Consent to Share and Release of Information (Revised january 2017)
By signing the Client Informed Consent to Share and Release of Information form, the client understands that any information s/he shares with an agency participating in HMIS is kept confidential and that only those authorized to input data into HMIS can view their personally identifying information; all health information, however, will not be shared. By signing this form, the client also understands s/he has the right to refuse to answer a certain question in HMIS and, furthermore, that if s/he decides at a later date they no longer want their information to be in HMIS, that s/he can request it be removed.
Projects, unless otherwise exempted, must obtain a signed Client Informed Consent to Share and Release of Information form from every client who will be entered into HMIS. Maintain the original, signed Client Informed Consent to Share and Release of Information form in client’s hard copy file. Agency will continue to maintain the original, signed Client Informed Consent to Share and Release of Information form for each client entered into HMIS for a minimum of three years from client’s program exit date.
HMIS Technology Equipment Reuse and Disposal Policy
Any computer, printers, copiers and fax machines that will no longer be used to access HMIS will have its hard drives reformatted multiple times before being used again by the Partner Agency or anyone else. A computer that is being disposed of will have its hard drives permanently destroyed and disposed of in a secure manner.
The agency will modify the form to reflect the agency’s information per the instructions. Once completed the original form will be mailed to the local ICA office with a copy maintained at the agency’s office. For more information, please contact the helpdesk.
Data/Report request policy and form
The St. Louis City and County CoCs have a policy for data requests, which breaks into data requests not requiring approval from the HMIS Committee and those that do require approval from the Committee. There is also a form that must be filled out for requests for either data from HMIS or custom reports inside HMIS.
Data Collection Forms
These optional data collection forms are available for agencies to use to collect of required data elements.
- HMIS Core Data Collection Forms (WORD)
- HMIS UDE Data Collection Forms (WORD)
- HMIS HUD Funded Program - Specific Data Collection Forms (WORD)
- HMIS HOPWA Funded Program - Specific Data Collection Forms (WORD)
- HMIS MHDC Funded Program - Specific Data Collection Forms (WORD)
- HMIS PATH Funded Program - Specific Data Collection Forms (WORD)
- HMIS RHY Funded Program - Specific Data Collection Forms (WORD)
- HMIS SSVF Funded Program - Specific Data Collection Forms (WORD)
- HMIS Veteran Information Adult-HoH Data Collection Form (WORD)