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Submit a Designation of Access Form

Overview

When completing the DOA form below, you must select at least one primary role and, if needed additional roles if required. Details on who each roles are designed for in this document

Designation of Access Form
                            License to be issued to*
                        
                            Organization Name*
                        
                            Phone*
                        
                            Email*
                        
                            HMIS Data Coordinator (HDC) Name*
                        
                            HMIS Data Coordinator (HDC) Email*
                        
                            Access level for License
                        
                            Role 1 - See Link at top of this form for details on each role.*
                        
                            Role 2
                        
                            Role 4
                        
                            Role 6
                        
                            Role 3
                        
                            Role 5
                        
                            Role 7
                        
                            Program Name 1*
                        
                            Program Name 2
                        
                            Program Name 3
                        
                            Program Name 4
                        
                            Program Name 5
                        
                            Program Type 1
                        
                            Program Type 2
                        
                            Program Type 3
                        
                            Program Type 4
                        
                            Program Type 5