APPLICATION CERTIFICATION & CONSENT

This agency may enter the personal information I have given them into the MAACLink and/or Service Point computer systems that operate inside secure and confidential networks of agencies by trained representatives. The information I have provided is true and correct. I understand that my information is electronically tracked in order to assess my household needs and provide better services such as housing, utility assistance, food and other services. My information may be shared among the agencies from which I have requested emergency assistance or case management. If I am applying for utility assistance, my identifying information may be shared with my utility provider by phone, email, or in written form in order to secure payment to the correct account. If I am applying for rental assistance, my identifying information may be shared with my landlord or property management company by phone, email, or in written form in order to secure payment to correct account.

CLIENT AND CONSTITUENT RIGHTS STATEMENT

If any client, donor, volunteer, vendor, or other member of the public feels he or she has been treated unfairly by the agency and the matter cannot be resolved informally through the immediate caseworker or other MLM employee, the following procedures for managing grievances shall apply. From this point forward donors, volunteers, vendors, and other members of the public will be referred to in this document as constituents.

STEP 1: The client shall provide a written statement describing the situation to the immediate supervisor of the case manager. The constituent shall provide a written statement describing the situation to the Executive Director. The written statement shall be provided as soon as possible but no later than thirty (30) days after the situation in question. Should the client or constituent need assistance with reading and/or writing a statement, another case manager or MLM staff member, not named in the grievance, will assist the client or constituent.

STEP 2: The supervisor shall meet with the client no later than five (5) business days following the receipt of the statement and attempt to provide a solution or explanation in writing within three (3) business days after meeting with the client, unless additional time is required under the circumstance. The Executive Director shall follow up with the constituent no later than five (5) business days following the receipt of the statement and attempt to provide a solution or explanation in writing within three (3) business days after meeting with the constituent, unless additional time is required under the circumstance.

STEP 3: If the grievance is not resolved to the client's satisfaction at this level, the client shall forward, within five(5) business days, a copy of the original statement, together with an explanation of previous attempts to resolve the issues, including the supervisor's written solution or explanation, to the Executive Director. Should the client need assistance with reading and/or writing a statement, another case manager or MLM staff member will assist the client. If the grievance is not resolved to the constituent's satisfaction at this level, further steps will be taken involve the Board of Directors or outside parties to assist in resolving the issue.

STEP 4: The Executive Director shall interview the client, the case manager, and the supervisor within five (5) business days of receiving the written statement.

STEP 5: The Executive Director shall respond within three (3) business days after meeting with the client, case manager, and supervisor, with a solution or explanation in writing, unless additional time is require under the circumstances. The determination of the Executive Director is final.

HMIS CONSENT

MAACLink and Service Point are computer systems used locally as a Homeless Management Information System (HMIS). Use of an HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. MAACLink and Service Point are not electronically connected to HUD and are only used by authorized agencies. All users have received confidentiality training and have signed strict agreements to protect clients’ personal information and limit its use appropriately.

A Privacy Notice is available at participating agencies. It provides details on how member agencies and their employees handle client information and data sharing.

I give permission to Metro Lutheran Ministry to collect and enter my personal and household information into the MAACLink and/or Service Point data systems.

 I understand that the MAACLink and Service Point systems are shared with and used by authorized agencies in my community for the purposes of:

 1.  Assessing the needs of low-income, homeless or other people with special needs in order to give better assistance and to improve their current or future situations.

2.  Improving the quality of care and service for people in need.

3.  Tracking the effectiveness of community efforts to meet the needs of people who have received assistance.

4.  Reporting data on an aggregate level that does not identify specific people or their personal information.

I understand that:

•         All agencies that use MAACLink and/or Service Point will treat my information in a professional and confidential manner.

•         Signing this release form does not guarantee that I will receive assistance.

•         My information may be shared with a third party (utility provider, landlord, etc) in order to process the service I have requested.

•         I have the right to a printed copy of my client file.