2017-745-E Health - Family Success Alliance Master Data Sharing Agreement United Way

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DocuSign Envelope ID: D6EB45D6-6C12-4C2B-895B-067AF17D828F Master Data-Sharing Agreement Attachment E: Consent Agreement for Data Disclosure and Sharing Orange County FSA Consent Agreement for Data Disclosure and Sharing By signing this agreement,you give your consent to disclose and share personally identifiable information on the person listed below with authorized partners in Orange County FSA.The purpose of sharing this information is to allow Orange County FSA to provide well-informed,coordinated services to participants and their families,to conduct ongoing evaluation and improvement of programs to better serve the community, and to report results of programs and activities to residents, partners, and funders. Orange County FSA takes every precaution to protect personally identifiable information from unauthorized use or disclosure. Information obtained on persons shall not be published in a manner that will lead to the identification of any individual.This information is used solely for service provision and program evaluation purposes and identified information shall not be further re-disclosed to third parties not covered by this Consent Agreement without your prior written consent. I understand that the records to be disclosed and shared with Orange County FSA may include but are not limited to • Education records from Orange County Schools &Chapel Hill Carrboro Schools • Enrollment information • Grade reports • Demographic information such as gender, economic status, disability status, English learner • Standardized test scores • Post-secondary enrollment information • Transcripts • Classroom performance/behavior • Attendance Program specific data, performance assessments, and records from Orange County FSA service providers, including • Intake information collected on participants(such as name, address, and date of birth) • Participation data (such as services received, attendance dates, and length of time participating) • Program results and assessments (such as tests results and observations by program staff) I consent to the disclosure of the personally identifiable information described above to the Orange County FSA entities and partners. Furthermore, I consent that the following parties may obtain the information described above stripped of any and all direct identifiers: • The U.S. Department of Education and its authorized contractor(s) For up-to-date information and questions, please go to http://www.orangecountync.gov/departments/health/FSA.Php or contact the Orange County FSA data 17