Tarrant County Homeless Coalition Data Request Form

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* 1. Requester’s Info

Date Request Needed (MM/DD/YYYY)

Requesters Name

Title

Organization/Institution

City/Town

State/Providence

Zip/Postal Code

Country

Email Address

Phone Number

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* 2. Do you have access to the Homeless Management Information System (HMIS)?

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* 3. Intended Use (please provide a brief description of why the requested data are needed and how the data will be used)

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* 4. Capacity of Data Request

Research Project

Consultation Purporse

Academic (Thesis/Dissertation)

Other (please specify)

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* 5. Will the data be disseminated, presented, or published?

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* 6. If yes, where will it be disseminated, presented, and published? (Please note that you must receive permission before submitting for publication. You must submit a draft of the publication to TCHC at least 30 days before the official publication day, which could be the date of the conference presentation, or article in the online/or print journal).

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* 7. Describe, in detail, the information you are requesting, including specific demographic variables (e.g., gender), the time-frame of data (e.g., October 1, 2018 to September 30, 2019), and variables of interest (e.g., number of occupied beds).

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* 8. Type of Calculations:

Counts

Rates

Percentages

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* 9. Type of Data Requested (A signed-data use agreement for each type of data is requested. This form can be found on our website HMIS page named "'de-identified' or 'identified' data use agreement".) Check the one that applies to you.

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* 10. Please sign and upload your signed-data use agreement here. (This form can be found on our website HMIS page named "'de-identified' or 'identified' data use agreement".)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.