HMIS Agency Agreements and Client Consent Forms

The West Central Illinois Continuum of Care Consortium (WCICCC) Steering Committee has developed a set operating forms for your agency’s use with the Homeless Management Information System (HMIS) database. The forms are required to be used by all participating agencies, and are described below (Adobe® Acrobat Reader® is required... click here to get the FREE Adobe® Acrobat Reader®). To see and print each form, click on the title of the form.

These forms are updated periodically. If you are a participating partner agency, your agency will be notified by email when an updated version of any form is available.

List of HMIS Partner Agencies (Revision Date: March 1, 2007)

The Client Consent—Release of Information form notifies all clients that they have the right to review a list of all the partner agencies that participate in the HMIS prior to signing the Client Consent form. If a client asks to see the list of partner agencies, you may click the above link and display this information to the client, or print out a list and give it to the client. This list is subject to frequent updates, so be sure to check this site for the latest list available.

 

Agency Partner Agreement (Revision Date: August 20, 2004)

This form is an agreement between your agency and the WCICCC. The YWCA of Quincy acts as the HMIS Program Administrator on behalf of WCICCC. 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. The Executive Director of your agency, or a person with similar responsibility, should read and sign this form. The form must be returned to WCICCC before your agency will be granted access to the HMIS database. You may either mail the form to Glenda Clark, YWCA, 1400 North 30th Street, Suite 6, Quincy, IL 62301, or fax the form(s) to Glenda Clark, 217.221.9926.

 

User Policy, Responsibility Statement and Code of Ethics (Revision Date: August 20, 2004)

Each person that your agency wishes to designate as a User of the HMIS database must fill this form out and sign it. The form describes the duties of HMIS users in keeping client information confidential and maintaining the security of the HMIS database. The form(s) must be returned to WCICCC before your agency will be granted access to the HMIS database. You may either mail the form to Glenda Clark, YWCA, 1400 North 30th Street, Suite 6, Quincy, IL 62301, or fax the form(s) to Glenda Clark, 217.221.9926.

 

Client Consent—Release of Information (Revision Date: August 20, 2004)

Every client your agency serves must read, understand, and sign this form before your agency may enter his or her information in the HMIS database. The purpose of the form is to ensure that all clients understand why they are being asked for the information collected in HMIS, and what it will be used for. When you serve multiple clients within the same family or household, the head of the household signs and gives consent on behalf of the other members of that household. Please photocopy this form and keep a supply on hand.

 

Client Revocation of Consent to Release Information (Revision Date: August 20, 2004)

Should a client wish to revoke his or her consent to share their information in the HMIS database, the Client must sign this form. The agency staff person assisting the client must also sign the form and immediately notify the agency of the revocation. The agency must then notify the HMIS Program Administrator (Glenda Clark of the YWCA of Quincy) of the revocation. Revocation means that the Client’s information is rendered invisible to all users in the database; the information remains for purposes of aggregate reporting only. You may either mail the form to Glenda Clark, YWCA, 1400 North 30th Street, Suite 6, Quincy, IL 62301, or fax the form(s) to Glenda Clark, 217.221.9926.

 

Sign for Intake Area 11" x 17" (Revision Date: August 20, 2004)

A sign must be posted at each intake desk (or comparable location) that explains, to Clients, the reasons for collecting information for the HMIS.

 

Paper Intake Form (Revision Date: January 14, 2005)

This is a sample of an paper intake form that another continuum uses with the HMIS software. Download and modify as needed.