Tarrant County Homeless Coalition Data Request Form Question Title * 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 OK Question Title * 2. Do you have access to the Homeless Management Information System (HMIS)? Yes No OK Question Title * 3. Intended Use (please provide a brief description of why the requested data are needed and how the data will be used to benefit public health) OK Question Title * 4. Capacity of Data Request Research Project Consultation Purporse Academic (Thesis/Dissertation) Other (please specify) OK Question Title * 5. Will the data be disseminated, presented, or published? Yes No Other (please specify) OK Question Title * 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 SARAH 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). OK Question Title * 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). OK Question Title * 8. Type of Calculations: Counts Rates Percentages OK Question Title * 9. Type of Data Requested (A signed-data use agreement for each type of data is requested). Check the one that applies to you. Non-Confidential Information (please sign and attach this form) Confidential Information (please sign and attach this form) OK Question Title * 10. Please sign and upload your signed-data use agreement here. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File Please sign and upload your signed-data use agreement here. OK DONE