New User License

This form must be completed by the program manager and then signed. To request End User access to the Rochester/Monroe County HMIS. In addition, the “User Policy, Responsibility Statement, And Code Of Ethics” form must be completed and signed before a user ID and Password will be assigned

User License Form

Agency Name *

Name of HMIS User *

Position/Title *

Email *

Phone *

Effective Date *

The Default Program/Shelter Type: *

Emergency

RRH

PSH

Street Outreach

RHY

SSVF

User Access Level *

Name of Person requesting the removal

Type of Access *

Does your Agency have multiple Programs/Sites that the user will need to access to:

Name of PRIMARY SITE/PROGRAM this person is assigned to: Default Provider

List all other programs/sites this person can“Enter Data As”: like coordinated entry for EH or other programs

Do you want to Modify Program/Site of Use on a certain date:

Date

HMIS Modules for Training: CHECK ONLY THE FUNCTIONS THE USER WILL BE PERFORMING

Priority List-(to enter on list)

Coordinated Entry Referral Notes (RRH PSH Only)

Notes/Case Manager/Goals

V-SPDATS

Entry/Exit

Move in Dates (USED BY RRH PSH Only)

Annual Assessments

Street Outreach

If you are human, leave this field blank.

Continuum of Care

560 West Main Street
Rochester, New York 14608
(585) 319‐5091

Homeless Services Network

560 West Main Street
Rochester, New York 14608

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