Required Signatures for New Intakes

Welcome to Evergreen!

Completion of this form is voluntary. It is your right to decline to provide any information you do not wish to disclose. Keep in mind that the more information you provide, the better we can connect you to the right services. By completing and signing this application, you are acknowledging that the information you’ve provided is true and correct to the best of your knowledge. Thank you for taking the time to complete this form and trusting us to serve you. Please note that if you are seeking assistance with finding new housing, the HMIS Data Privacy Notice must be signed and the 'Shared' box must be checked. This will allow you to be put on the Northwest Minnesota Housing Priority List.
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Minnesota's HMIS Data Privacy Notice

We collect personal information about the people we serve in a computer system called Minnesota’s HMIS (Homeless Management Information System). Many social service agencies use this computer system, including street outreach, shelters, and housing programs.
Why do we collect this information?
• To help keep this program and others like it going. We are required to use HMIS.
• So we know how many people we serve and the types of people we serve at our agency and in the state.
• So we all understand what people need and can plan services to meet these needs.

Who can see information that is in Minnesota’s HMIS?
• People who work for this agency will use it to help provide services to you or your family.
• Other agencies like this agency that provide services and have received permission from you to see your information. The agencies that participate in Minnesota’s HMIS may change from time to time. A copy of the current list of participating agencies is available upon request.
• Auditors or funders who have legal rights to review the work of this agency, such as the U.S. Department of Housing and Urban Development and other state or local government entities.
• Organizations that run, administer, and work on the system, such as the Institute for Community Alliances or Local System Administrators. When these organizations work on the system, they may see information about you.
• People using HMIS information to do research and write reports, including, but not limited to, the Minnesota Department of Human Services (DHS). Your personally identifiable information will never appear in research reports.
• The law says we have to report physical or sexual abuse of children and vulnerable adults. If we think there is abuse or neglect in your household, we will report it to Child or Adult Protection.
• We may release your information to protect the health or safety of you or others as required by law.
• Others as required by law, including officials with a valid subpoena, warrant, or court order.

We will not release your information for any other use unless you permit us in writing.

How is your privacy protected?
• All users of data must sign an agreement to protect your privacy and comply with state and federal laws and policies before seeing any information.
• The computer program used for this purpose has industry standard security protocols and is updated regularly to meet these security requirements.

What are your rights?
• If you do not want your name, social security number, or date of birth entered in HMIS, tell the intake worker. This agency will not refuse to help you for denying this. However, federal and state regulations may require limited data collection for funding purposes.
• You have the right to request a copy of the Minnesota’s HMIS information about you.
• You have the right to correct mistakes in HMIS information about you.
• If you think this agency or Minnesota’s HMIS violated your privacy rights, you have the right to complain or appeal. Ask a staff person for a complaint and appeal form.
Your personal information will be collected in Minnesota’s HMIS and, with your consent, shared with other service providers/homeless agencies. If you do not give permission for this agency to share your information, no other agency in the network will have access to it.

Why share your information?
• Sharing reduces the amount of time you have to spend answering basic questions about your situation.
• Sharing allows agencies to focus on meeting your unique needs more quickly.
• Sharing makes it easier for multiple agencies to coordinate housing and services for you and your family.

What information might be shared?
• Family/Household information
• Name, birthdate, Social Security Number
• Gender, race, ethnicity
• Reasons for seeking services
• Living situation and housing history
• Services you receive
• If you are homeless or not
• Your income and income sources
• Public benefits you receive
• History of domestic violence
• Educational background
• Employment information
• Military history
• Health information, including physical health, HIV, behavioral health
Please check (✓) a box:*

SHARE: I consent to have the information collected about me shared through Minnesota’s HMIS with other partner agencies in order to improve services to me and the services offered to others.DO NOT SHARE: I do not want any of the information about me in Minnesota’s HMIS shared with any other service providers/homeless agencies. I understand that not sharing my information may affect the ability to quickly and appropriately identify services for me.
When you sign this form, it shows that you understand the following.
• We will not deny you help if you do not want us to share your personal information. At the same time, sharing data does not guarantee that you will receive assistance.
• If you permit us to share your information, this consent is valid until canceled by you.
• If you permit us to share your information, you may change your mind and cancel this consent at any time. If you cancel this consent, your information will no longer be shared from that date forward.
Minnesota HMIS Data Sharing Authorization Signature*

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HMIS Staff Signature

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Please treat information about my children age 17 or younger the same as mine*

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Tennessen Warning

Data Privacy Rights for Applicants/Recipients of Program Sponsored By Evergreen Youth & Family Services
YOUR RIGHTS:

Under the Minnesota Data Privacy Act, you have the right to know how the information you provide on the application for a program will be used.
THE INFORMATION YOU PROVIDE WILL BE USED TO:

Determine your eligibility for a specific program, which requires sharing information with other Evergreen Youth & Family Services employees. Information gathered will also assist us in identifying other community based resources you may be eligible for.
REFUSAL TO PROVIDE DATA:

You may refuse to provide the data. This may prevent you from obtaining services from certain programs that require the data and our services to you may be limited. You do not have to provide a Social Security Number to be eligible for our programs. Federal Privacy Act and Freedom of Information Act dictate the use of the Social Security Number. We may use it for computer matches, programs reviews and audits. We will ask you for your Social Security number for these purposes only and will not share that information unless dictated by law.
AUTHORIZATION BY LAW TO SHARE INFORMATION

Evergreen Youth & Family Services is required bylaw to report aggregate statistical and demographic data on clients to state, federal and other federal monitors. Case files may be reviewed during required site visits. With your informed consent, we may also share it with community agencies, local and state human service agencies, local government, educational programs, Minnesota Housing Financial Agency, DHS-OEO, DHS Adolescent Services, DHS Supportive Services, LTH, HUD, and other agencies that help you.
By signing this you are acknowledging that you understand your data privacy rights and how information you share with this agency will be used.*

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Staff Signature - Tennessen Warning

Clear
Statement on Mandated Reporting
Staff employed at the Evergreen Youth & Family Services are mandated by law to report all “firsthand” information regarding physical, sexual, and/or emotional abuse, as well as neglect of youth under the age of 18 to Beltrami County Human Services and/or the Law Enforcement Center.
In the event an employee of Evergreen suspects abuse, danger, and/or neglect, staff will:
Complete an Evergreen Youth & Family Services Maltreatment of Minors Report describing the details and nature of the reported abuse and/or neglect.

Forward the report within one business day to the intake worker at Beltrami County Human Services.

If the reported abuse constitutes imminent danger to a minor child, Evergreen staff will contact Beltrami County Law Enforcement Center

If client reports abuse of child, unborn child, or vulnerable adult (developmentally disabled or elderly); staff will complete a Maltreatment of Vulnerable Adults form.

If client declares that they are going to cause harm to themselves or another person Evergreen staff will contact Bemidji Law Enforcement Center immediately.
I have read and understand the above information:*

Clear
Staff Signature - Mandated Reporting

Clear
Legal Name*

First NameLast Name
Preferred Name
Date of Birth*

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Welcome to Evergreen!

Minnesota's HMIS Data Privacy Notice

Tennessen Warning

YOUR RIGHTS:

THE INFORMATION YOU PROVIDE WILL BE USED TO:

REFUSAL TO PROVIDE DATA:

AUTHORIZATION BY LAW TO SHARE INFORMATION

Statement on Mandated Reporting

In the event an employee of Evergreen suspects abuse, danger, and/or neglect, staff will: