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2. Homeless Management Information Systems (HMIS) Correction Request Form
4. Title II Compliance
   In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.
6. Date of Request*
   Date of Request

   Date of Request
8. Organization Name*
10. User First Name*
11. User Last Name*
12. Email Address*
14. Contact Phone Number*
15. Extension
19. Type of Request: Delete Enrollment, Delete Service, Duplicate/Merge Client, Change Enrollment
21. Type of Request*

    Please check all the changes being requested

    1. Delete Enrollment
    2. Delete Service
    3. Change Enrollment
    4. Duplicated/Merge Clients
    5. Other
25. Name of Program Enrollment to be Delete*
    Full program name that the client is enrolled in
26. Enrollment Date*
    Enrollment Date
    Date Client Enrolled
28. a. Client ID*
29. a. Name of Client*
31. Reason for request*
35. Name of Service to be Deleted*
36. Date of Service*
    Date of Service
38. a. Client ID*
39. a. Name of Client*
41. Reason for the Request*
45. Name of Program Enrollment to be Changed*
    Full program name that the client is enrolled in
46. Enrollment Date*
    Enrollment Date
    Date Client is enrolled
48. Name of New Enrollment*
50. a. Client ID*
51. a. Client Name*
53. Reason for the Request*
57. a. Client ID*
58. a. Name of Client*
60. b. Client ID*
61. b. Client Name*
63. c. Client ID*
64. c. Client Name*
66. d. Client ID*
67. d. Client Name*
69. Which Client ID listed above is Correct?*
    -- Select One --abcd
71. How was it verified?*
    Describe the method of verification.
75. Description of Other Requests*
    Please fill in a detailed report of the issue or correction that you are experiencing
77. Upload a screen shot
    Upload a screen shot or file of what you are experiencing.
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit Submit and Print

* indicates a required field