CTHMIS Support Form – Submit a Designation of Access Form

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CT HMIS - Submit a Designation of Access Form

When completing the DOA form below, you must select at least one primary role and, if needed additional roles if required.

View our Role Guide: Details on each role, its associated programs types and who that role is for, will help guide you in completing the form.

License to be issued to(Required)

First Last

Organization Name(Required)

Phone(Required)

Email(Required)

HMIS Data Coordinator (HDC) Name*(Required)

HMIS Data Coordinator (HDC) Email*(Required)

Access Level for License(Required)

Does this user need Data Warehouse Access?(Required)

Data Warehouse access requires an additional license fee, please contact your HDC or lodge a General Help Desk Ticket if you have any questions.

View our Role Guide: Details on each role, associated programs types and who that role is for.

Role 1(Required)

Role 1 Other (may require approval)

Role 2

Role 3

Role 2 Other (may require approval)

Role 3 Other (may require approval)

Role 4

Role 5

Role 4 Other (may require approval)

Role 5 Other (may require approval)

Role 6

Role 7

Role 6 Other (may require approval)

Role 7 Other (may require approval)

Program Name 1(Required)

Program Type 1(Required)

Program Name 2

Program Type 2

Program Name 3

Program Type 3

Program Name 4

Program Type 4

Program Name 5

Program Type 5

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