IMPORTANT: DO NOT CONSENT to share personally identifying information in HMIS if you are::
Participating in a Domestic Violence agency program or shelterCurrently fleeing or in danger from a domestic violence, dating violence, sexual assault or stalking situation
Being served in a program that requires disclosure of HIV/AIDS status (i.e. HOPWA)
Under 13 years of age with no parent/guardian available to consent to sharing the minor’s information in HMIS
If one or more of these applies to you, check the DO NOT CONSENT option and sign.
Agency Name: Family Promise of Pierce County. The organization collecting this consent is a Participating Agency in the Pierce County Clarity Homeless Management Information System (HMIS) and collects information, over time, about the characteristics and service needs of people experiencing homelessness. RCW 43.185C.180. This consent is collected from the Head of the Household. If you consent, you and your household members will have your name and other personally identifying information available to Partner Agencies, Pierce County Human Services, Pierce County contracted Research Groups and the Washington State HMIS for seven (7) years. Please read the following Frequently Asked Questions and Answers, and make sure to discuss this and any other questions you have prior to signing this form.Q: Do I have to sign this form in order to get help?
A: Your decision to participate in the HMIS will not affect the quality or quantity of services you are eligible to receive from this agency and will not be used to deny outreach, assistance, shelter or housing. (Please note: You cannot receive financial assistance from a Supportive Services for Veteran Families project without the eligible veteran’s consent to enter their full social security number into the HMIS).
Q: Why does my information need to be collected or put into a database?A: 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 Pierce County. In order to ensure that individuals are not counted twice, we need to collect personally identifying information. Specifically, we ask for name, date of birth, social security number, demographics, contact information, last and future permanent addresses, use of crisis services, hospitals, and jail, and services provided by Partner Agencies. The information you provide helps us coordinate the most effective services for you and your household members.
Q: If my personally identifying information is entered into a database, how will I know that it is safe and confidential?A: 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 identity checks required for each system user. There is a small risk of a security breach, and someone might obtain and use your information inappropriately. If you ever suspect the data in HMIS has been misused, immediately contact agency staff or the HMIS System Administrator at (253) 798-4505.
Q: What happens with my information once it is entered into this database?A: As you receive services, information will be collected about you, the services provided to you, and the outcomes these services helped you to achieve. This information will be collected so that the agency and community can monitor the outcomes of services that are provided to you, improve the quality of care and services for homeless individuals and families, and ensure that your information is not duplicated in the system by Partner Agencies.
The organization collecting this consent is asking your permission to collect and share information with Partner Agencies—such as other homeless service, employment, education, social service, healthcare, and basic needs service providers—as well as Pierce County Human Services and the Washington State Homeless Management Information System (HMIS) in the planning and delivery of services to you. A list of Partner Agencies will be made available upon request. You may revoke your consent at any time, in writing. However, information already entered into the system cannot be removed. If you revoke your consent, no new information about you will be entered and current information will be hidden. (Note: this does not include any historical data.) Please ask the staff person you are working with all your questions about collection of data or your rights regarding your personally identifying information, so that you clearly understand what you are signing, what is being collected, and why. The agency listed above is asking your permission to collect and share information with other Partner Agencies—such as other homeless service, employment, education, social service, or basic needs service providers, etc.— Pierce County Community Connections and the Washington State Homeless Management Information System (HMIS) in the planning and delivery of services to you. A list of Partner Agencies will be made available upon request. You may revoke your consent at any time, in writing. However, information already entered into the system cannot be removed. If you revoke your consent, no new information about you will be entered and current information will be hidden. (Note: this does not include any historical data.) *I DO consent to the inclusion of personally identifying information about me and my dependents (listed below) and authorize information collected to be shared in the Pierce County HMIS. Personally identifying information includes name, social security number, date of birth, demographics, and last and future permanent addresses. Non-identifying information will still be collected and shared only as needed and required by funders.So they can verify eligibility and information that I have given as part of my application to Emergency Shelter in Pierce County. This release also authorizes the above-listed agencies to provide information they may possess about me and my household back to my case manager and the Family Promise of Pierce County Staff.
This consent may be revoked (canceled) by me at any time unless action has been taken in reliance on it. If I want to revoke this consent, I understand that I can do so by mailing out or emailing to: Mail: Family Promise of Pierce County Program Staff 16815 Pacific Ave S #1203 Spanaway, WA 98387