1Organization Information2Organization Policy3Disposal Policy4Device Security Policy5Other Policy6Confirmation Organization Name*Number of Licensed HMIS Users*Please enter a number greater than or equal to 1.Funding Sources* CoC ESG ESG-CV PATH RHY SSVF Private Primary Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Different Mailing Address Same as physical address Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please describe your policy on data collection and when it is entered into HMIS (ex. Real time, collect on paper and then enter, etc.). Be sure to include the organization's HMIS Timeliness policy standards.*Do you have hard and/or electronic copies of the HMIS Privacy Statement available?* Hard Copy Electronic Copy Hard & Electronic Copy None Please describe the training staff members receive on hard copy data protections (i.e., Physical Client Files).*Please describe the procedures your agency has in place to protect hard copy and/or electronic PPI information generated from or for the HMIS.*Please upload the most recent copy of the HMIS Policy and Procedure Manual.*Accepted file types: pdf, doc, docx, Max. file size: 20 MB.Please upload your agency's Privacy Policy.*Accepted file types: pdf, doc, docx, Max. file size: 20 MB.Please upload a photo of the HMIS Privacy Statement posted in common areas where clients can see it.Accepted file types: jpg, pdf, Max. file size: 20 MB. Does your agency dispose of or remove identifiers from a client record after a specified period of time? What is the timeframe?*What is your agency's policy on disposing hard copy PPI or Electronic Media?*Please describe the training staff members receive on proper disposal of data.* TRUE OR FALSE: End users are allowed to have their HMIS username and password in a public place or on a sticky note on their desk.* True False Are all workstations password protected?* Yes No Please upload a photo of each work area. Include the desk area and the computer in locked state (i.e., sign-in screen).* Drop files here or Select files Accepted file types: jpg, png, Max. file size: 20 MB, Max. files: 20. Upload up to 20 photos.Please upload a photo of your virus protection software console from each computer with the update settings visible.* Drop files here or Select files Accepted file types: jpg, png, Max. file size: 20 MB, Max. files: 20. Upload up to 20 photos. Hint: Use the snipping tool or photo from your phone.Please upload a photo of the firewall program protecting each computer from outside intrusion.* Drop files here or Select files Accepted file types: png, jpg, Max. file size: 20 MB, Max. files: 20. Upload up to 20 photos. Hint: Use the snipping tool or photo from your phone.Upload a photo of each computer set to automatically lock after a maximum of 10 minutes of inactivity.* Drop files here or Select files Accepted file types: jpg, png, Max. file size: 20 MB, Max. files: 20. Upload up to 20 photos. Hint: On Windows 10 open the start menu and type “Change screen saver” and select the “Change screen saver” option.Please upload a photo of each computer showing your secured internet connection settings.* Drop files here or Select files Accepted file types: jpg, png, Max. file size: 20 MB, Max. files: 20. Upload up to 20 photos.Please provide a copy of your agency's policy on internet and data security if work is taken outside of the office.*Max. file size: 20 MB.Are all printers accessed with an access code or in a secure location where ONLY staff is present?* Yes No Where are the printers located? What safety/security precautions are taken?* What is the procedure as it relates to court orders or law enforcement requests of Client HMIS Data?*Have all staff members been trained on how to assist clients who are not English proficient or have a disability?* Yes No What is your agency's policy in regards to assisting clients who are not English proficient or have a disability?* Your Name* First Last TitleEmail Address* Certification* I certify that this information is true.