Assessment & Diversion Signature Form

The Homeless Management Information System (HMIS) is a computerized data collection system designed to collect client information about the characteristics and service needs of individuals and households experiencing homelessness. The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD). Dallas City & County/Irving CoC HMIS Provider is Eccovia Solution’s Client Track and client information is shared across all CoC participating providers.

This Organization provides services for individuals and families at-risk of or experiencing homelessness. This Organization participates in the MDHA Homeless Management Information System (HMIS) and/or Coordinated Access System (CAS). The MDHA HMIS is used to collect basic information about clients receiving services from this Organization. This requirement was enacted to get a more accurate count of individuals and families experiencing homelessness, and to identify the need for different services. The MDHA CAS is used to connect individuals and families at-risk of or experiencing homelessness to the services they need. The HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. HMIS is not electronically connected to HUD and is only used to share information by local authorized agencies. This Organization only collects information that is considered appropriate and necessary. The collection and use of all personal information are guided by strict standards of privacy and security. This Organization may use or disclose information from the MDHA HMIS and/or the MDHA CAS under the following circumstances: • To provide or coordinate services for an individual or household; • For functions related to payment or reimbursement for services; • To carry out administrative functions; • When required by law; • For research and/or evaluation; • For creating de-identified data; or • To prevent or lessen a serious and imminent threat to the health or safety of an individual or the public in general A copy of the MDHA CoC Privacy Policy, describing allowable uses and disclosures of data collected for the purposes of the MDHA HMIS and/or the MDHA CAS, is available to all clients upon request. This privacy notice and the privacy policy may be amended at any time and those amendments may affect information obtained by the organization before the date of the change. Public Notice (Federal Register / Vol. 69, No. 146) / Effective August 30, 2004

SharePoint is a Microsoft cloud-based file management system that Family Gateway uses to securely store client documentation. The purpose of SharePoint is to safely store client documents as required by all funders for up to 10 years.

Family Gateway collects client data and documentation for the following purposes: - To provide the most effective services in moving people from homelessness to permanent housing, we need an accurate count of all people experiencing homelessness in Dallas City & County/Irving CoC. In order to ensure that clients are not counted twice, we need to collect four pieces of personally identifying information. Specifically, we collect: name, birth date, and race/ethnicity. You may also choose to provide your social security number. However, signing this form does not require you to do so. Your information will be stored in our database. - We use strict security policies designed to protect your privacy. Our computer system is highly secure and uses up-to-date protection features such as data encryption, passwords, and two-factor authentication required for each system user. There is a small risk of a security breach, and someone might obtain and use your information inappropriately. - Only a limited number of staff members, who have signed confidentiality agreements, will be able to see this information.

- Provide quality services to you - Increase access to housing - Improve access to services - Decrease need to share personal information when accessing multiple services within the system - Contribute to aggregate data used to improve the homeless service system Types of identifying data collected include: - Name - Address - Zip code - Phone number - Date of birth - Social security number - Your family status - The nature of your situation and the types of services you receive from an agency - Project entry and/or exit date, and - Unique personal identification number (HMIS Unique Identifier). Reasons data is collected, used and/or disclosed by the agency and/or CoC: - To Provide services to you - For functions related to funding for services - For administrative purposes, planning and personnel decisions - To research and better understand homelessness in the community - To provide a government required count(s) of people receiving services by HMIS participating agencies - Meet requirements of funders such as the U.S. Department of Housing and Urban Development (HUD) - Develop and improve programs to work towards ending homelessness in our community

With this form, you can give permission to have information about you collected and shared with Partner Agencies that help Dallas City &County/Irving CoC provide housing and services and are made aware that your information will be collected in the HMIS database. A current list of Partner Agencies is attached.

- All information entered and documentation saved in HMIS and SharePoint is protected and secured to protect your privacy. - Only agency staff members, database administrators, or auditors who have signed a confidentiality agreement will be allowed to see, enter, or use the information entered into HMIS and SharePoint. - Based on your needs, your information may be shared to coordinate referrals for housing and services or to coordinate services such as food, utility assistance, counseling, etc. - Information that does not identify you may be used for research in order to increase housing options and improve services. Your rights: - You have the right to see your information in HMIS and SharePoint, ask for changes, or ask for a printed copy upon request. - Identifying Information stored in HMIS and SharePoint will not be given to anyone outside the system without written consent, except as required by law through a court order or in the event of a public health emergency. - Only information deemed necessary/appropriate to meet goals above will be collected.

- Family Gateway, Dallas City & County/Irving CoC, and Partner Agencies will keep my HMIS and SharePoint information and documentation private using strict privacy policies. I have the right to review their privacy policies. - There is a small risk of a security breach, and someone might obtain my information and use it inappropriately. - If I have questions about my privacy rights, my HMIS information, my SharePoint documentation or am concerned that my information has been misused, I can contact Family Gateway’s Director of Program Evaluation & Compliance. - I can receive a copy of this Consent - I may refuse to sign this Consent. If I refuse, I will not lose benefits or services, but they will be limited as HMIS participation is required by most CoC funders including HUD. I understand the above statements and consent to the inclusion of personally identifying information and documentation in HMIS and SharePoint about me and any dependents listed below, and authorize information collected to be shared with partner agencies. I understand that my personally identifying information will not be made public and will only be used with strict confidentiality. I also understand that I may withdraw my consent at any time in writing with this agency. I understand that I may obtain a copy of my signed consent form from this Agency (including forms signed electronically).

I hereby authorize Family Gateway and any of its employees to obtain and/or discuss information regarding myself or my family with potential and/or past service providers. The disclosure of information authorized herein is made for the purpose of coordinating housing stability for the aforementioned family, and such disclosure shall be limited to the following specific types of information: social, mental, emotional and casework assessment. I acknowledge & understand that any information shared will only be shared with organizations that are working with Family Gateway for my benefit. I also understand that the information will be used as a means to assist me in creating a plan of action to begin work on my goals and objectives. Information may be shared for a period that does not expire, unless written request for expiration is given, regarding the welfare of the above-named client(s) and family. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance of such information. I give Family Gateway staff permission to share relevant information with partner organizations, which I and Family Gateway deem necessary to assist me in developing a community support system for my family to become self-sufficient.

To best serve you and your family, we require criminal history examination, especially those incidents that may affect safety and security. Having a Criminal History DOES NOT disqualify you from our program, unless it violates our safety and security policy which does not allow enrollment of any family members who are convicted of a violent offense, crime against a minor, and/or are a registered sex offender. I hereby give permission to Family Gateway to obtain information relating to my criminal history record through the Public State, County, and City Criminal Records. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications. I understand that this information will be used, in part, to ensure that my enrollment does not violate the safety and security policy of the agency. I also understand that as long as I remain a program participant the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received. I, undersigned, do, for myself, my heirs, executors and administrator, hereby remise, release and forever discharge and agree to identify the Volunteer Center of Dallas County, Family Gateway and each of their officers, directors, employees and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sum of money, claims and demands whatsoever and any and all related attorney’s fees, count costs, and other expenses resulting from investigation of my background in connection with my application to become a volunteer, staff member or program participant.

To best serve you and your family, we require criminal history examination, especially those incidents that may affect safety and security. Having a Criminal History DOES NOT disqualify you from our program, unless it violates our safety and security policy which does not allow enrollment of any family members who are convicted of a violent offense, crime against a minor, and/or are a registered sex offender. I hereby give permission to Family Gateway to obtain information relating to my criminal history record through the Public State, County, and City Criminal Records. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications. I understand that this information will be used, in part, to ensure that my enrollment does not violate the safety and security policy of the agency. I also understand that as long as I remain a program participant the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received. I, undersigned, do, for myself, my heirs, executors and administrator, hereby remise, release and forever discharge and agree to identify the Volunteer Center of Dallas County, Family Gateway and each of their officers, directors, employees and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sum of money, claims and demands whatsoever and any and all related attorney’s fees, count costs, and other expenses resulting from investigation of my background in connection with my application to become a volunteer, staff member or program participant.

I hereby authorize VERIFYI and or its Service Provider to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Social Security Number Trace including a consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers. The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged. I further release and discharge VERIFYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I understand that I have the right to make written request within a reasonable period of time to VeriFYI for additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the above information for employment/volunteer purposes, and I have carefully read and understand this authorization.

I hereby authorize VERIFYI and or its Service Provider to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Social Security Number Trace including a consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers. The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged. I further release and discharge VERIFYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I understand that I have the right to make written request within a reasonable period of time to VeriFYI for additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the above information for employment/volunteer purposes, and I have carefully read and understand this authorization.