Common use of MANDATORY COLLECTION NOTICE Clause in Contracts

MANDATORY COLLECTION NOTICE. We collect personal information directly from you for reasons that are discussed in our privacy statement. We may be required to collect some personal information as mandated by law or as requested from entities that fund this program. Other personal information we collect is necessary to operate programs, improve services, and better understand homelessness. We collect appropriate information only. A Privacy Notice is available upon request. San Diego County CoC Homeless Management Information System (HMIS) Client Revocation of Authorization to Release Information I, , hereby revoke permission for this agency to share my personal information in the San Diego County CoC Homeless Management Information System (HMIS) and also revoke my permission to share my data to the Community Information Exchange (CIE). I understand that my information will remain in HMIS as part of the non-identifying data collected on homeless services provided by the San Diego County Continuum of Care (CoC) and I understand that my information will only be used according to the procedures outlined in the RTFH’s HMIS Notice of Privacy Practices document. I understand that information that has already been entered will remain in the system. By canceling my agreement for sharing information within the HMIS, my personal information that has been saved will be restricted. I further understand that this revocation of data sharing only applies to information within the HMIS. Any information which was shared or retained outside of HMIS is not affected by this revocation. By signing, I acknowledge and understand that this Client Revocation of Consent to Release Information applies only to the sharing of information within the HMIS from this day forward. I also understand that the disclosure of my non-identifying information may be required in some instances which are outlined in the RTFH’s HMIS Notice of Privacy Practices document. The San Diego County CoC HMIS Lead Agency and this agency are hereby released from any legal responsibility or liability for the release, use or disclosure of information I previously authorized. Client Name Date of Birth Social Security Number Client Signature Date Agency Staff Agency Staff Signature Agency Name Date San Diego County CoC Homeless Management Information System (HMIS) How to File a Privacy Complaint If you feel that a violation of your rights as an HMIS client has occurred, or if you disagree with a decision that has been made about your Protected HMIS Information, you may complete this form and submit to the HMIS Lead Agency, the Regional Taskforce on the Homeless. Please complete this form only after you have exhausted the grievance procedures for the agency providing you housing and/or services. It is against the law for any agency to take retaliatory action against you if you file this grievance. You can expect a response within 30 (thirty) days via the grievance method of your choice. Grievances must be submitted in writing to: Regional Taskforce on the Homeless 0000 Xxxxxx Xxxxxx Rd. San Diego, CA 92123 Brief Description of grievance (what happened): Date(s) of offense(s) Name of Individual(s) who violated your rights Name of Agency(ies) who violated your rights Your Contact Information Your Name Phone Number and/or Email Address Mailing Address Today’s Date HMIS Lead Agency Use Only Response Date Recommendation to Agency San Diego County CoC Homeless Management Information System (HMIS) Policies and Procedures Legal Framework

MANDATORY COLLECTION NOTICE. We collect personal information directly from you for reasons that are discussed in our privacy statement. We may be required to collect some personal information as mandated by law or as requested from entities that fund this program. Other personal information we collect is necessary to operate programs, improve services, and better understand homelessness. We collect appropriate information only. A Privacy Notice is available upon request. San Diego County CoC Homeless Management Information System (HMIS) Client Revocation of Authorization to Release Information I, , hereby revoke permission for this agency to share my personal information in the San Diego County CoC Homeless Management Information System (HMIS) and also revoke my permission to share my data to the Community Information Exchange (CIE). I understand that my information will remain in HMIS as part of the non-identifying data collected on homeless services provided by the San Diego County Continuum of Care (CoC) and I understand that my information will only be used according to the procedures outlined in the RTFH’s HMIS Notice of Privacy Practices document. I understand that information that has already been entered will remain in the system. By canceling my agreement for sharing information within the HMIS, my personal information that has been saved will be restricted. I further understand that this revocation of data sharing only applies to information within the HMIS. Any information which was shared or retained outside of HMIS is not affected by this revocation. By signing, I acknowledge and understand that this Client Revocation of Consent to Release Information applies only to the sharing of information within the HMIS from this day forward. I also understand that the disclosure of my non-identifying information may be required in some instances which are outlined in the RTFH’s HMIS Notice of Privacy Practices document. The San Diego County CoC HMIS Lead Agency and this agency are hereby released from any legal responsibility or liability for the release, use or disclosure of information I previously authorized. Client Name Date of Birth Social Security Number Client Signature Date Agency Staff Agency Staff Signature Agency Name Date San Diego County CoC Homeless Management Information System (HMIS) How to File a Privacy Complaint If you feel that a violation of your rights as an HMIS client has occurred, or if you disagree with a decision that has been made about your Protected HMIS Information, you may complete this form and submit to the HMIS Lead Agency, the Regional Taskforce on the Homeless. Please complete this form only after you have exhausted the grievance procedures for the agency providing you housing and/or services. It is against the law for any agency to take retaliatory action against you if you file this grievance. You can expect a response within 30 (thirty) days via the grievance method of your choice. Grievances must be submitted in writing to: Regional Taskforce on the Homeless 0000 4600 Xxxxxx Xxxxxx Rd. San Diego, CA 92123 Brief Description of grievance (what happened): Date(s) of offense(s) Name of Individual(s) who violated your rights Name of Agency(ies) who violated your rights Your Contact Information Your Name Phone Number and/or Email Address Mailing Address Today’s Date HMIS Lead Agency Use Only Response Date Recommendation to Agency San Diego County CoC Homeless Management Information System (HMIS) Policies and Procedures Legal Framework

MANDATORY COLLECTION NOTICE. We collect personal information directly from you for reasons that are discussed in our privacy statement. We may be required to collect some personal information as mandated by law or as requested from entities that fund this program. Other personal information we collect is necessary to operate programs, improve services, and better understand homelessness. We collect appropriate information only. A Privacy Notice is available upon request. San Diego County CoC HMIS Mandatory Collection Notice Page 1 of 1 San Diego County CoC Homeless Management Information System (HMIS) HMIS)‌ Client Revocation of Authorization to Release Information I, , hereby revoke permission for this agency to share my personal information in the San Diego County CoC Homeless Management Information System (HMIS) and also revoke my permission to share my data to the Community Information Exchange (CIE). I understand that my information will remain in HMIS as part of the non-identifying data collected on homeless services provided by the San Diego County Continuum of Care (CoC) and I understand that my information will only be used according to the procedures outlined in the RTFH’s HMIS Notice of Privacy Practices document). I understand that information that has already been entered will remain in the system. By canceling my agreement for sharing information within participation in the HMIS, my personal information that has been saved will be restricted. I further understand that this revocation of data sharing only applies any information entered and/or shared under my previously agreed-to information within the HMIS. Any information which was consent will continue to be shared or retained outside of HMIS is not affected by this revocation. By signing, I acknowledge and understand that this Client Revocation of Consent to Release Information applies only to the sharing of any information within entered into the HMIS from this day forward. I also understand that the disclosure of my non-identifying information may be required in some instances which are outlined in instances, such as for the RTFH’s HMIS Notice reporting of Privacy Practices documentaggregate and to entities that provide funding to this agency. The San Diego County CoC HMIS Lead Agency and this agency are hereby released from any legal responsibility or liability for the release, use or disclosure of information I previously authorized. Client Name Date of Birth Social Security Number Client Signature Date Agency Staff Agency Staff Signature Agency Name Date San Diego County CoC HMIS Client Revocation of Consent to Release Information Page 1 of 1 San Diego County CoC Homeless Management Information System (HMIS) HMIS)‌ How to File a Privacy Complaint If you feel that a violation of your rights as an HMIS client has occurred, or if you disagree with a decision that has been made about your Protected HMIS Information, you may complete this form and submit to the HMIS Lead Agency, the Regional Taskforce on the Homeless. Please complete this form only after you have exhausted the grievance procedures for the agency providing you housing and/or services. It is against the law for any agency to take retaliatory action against you if you file this grievance. You can expect a response within 30 (thirty) days via the grievance method of your choice. Grievances must be submitted in writing to: Regional Taskforce on the Homeless 0000 Xxxxxx Xxxxxx Rd. San Diego, CA 92123 Brief Description of grievance (what happened): Date(s) of offense(s) Name of Individual(s) who violated your rights Name of Agency(ies) who violated your rights Your Contact Information Your Name Phone Number and/or Email Address Mailing Address Today’s Date HMIS Lead Agency Use Only Response Date Recommendation to Agency San Diego County CoC HMIS Privacy Grievance Procedure Page 1 of 1 San Diego County CoC Homeless Management Information System (HMIS) HMIS)‌ Policies and Procedures Legal Framework

MANDATORY COLLECTION NOTICE. We collect personal information directly from you for reasons that are discussed in our privacy statement. We may be required to collect some personal information as mandated by law or as requested from entities that fund this program. Other personal information we collect is necessary to operate programs, improve services, and better understand homelessness. We collect appropriate information only. A Privacy Notice is available upon request. San Diego County CoC Homeless Management Information System (HMIS) HMIS Mandatory Collection Notice Page 1 of 1 Client Revocation of Authorization to Release Information I, , hereby revoke permission for this agency to share my personal information in the San Diego County CoC Homeless Management Information System (HMIS) and also revoke my permission to share my data to the Community Information Exchange (CIE). I understand that my information will remain in HMIS as part of the non-identifying data collected on homeless services provided by the San Diego County Continuum of Care (CoC) and I understand that my information will only be used according to the procedures outlined in the RTFH’s HMIS Notice of Privacy Practices document). I understand that information that has already been entered will remain in the system. By canceling my agreement for sharing information within participation in the HMIS, my personal information that has been saved will be restricted. I further understand that this revocation of data sharing only applies any information entered and/or shared under my previously agreed-to information within the HMIS. Any information which was consent will continue to be shared or retained outside of HMIS is not affected by this revocation. By signing, I acknowledge and understand that this Client Revocation of Consent to Release Information applies only to the sharing of any information within entered into the HMIS from this day forward. I also understand that the disclosure of my non-identifying information may be required in some instances which are outlined in instances, such as for the RTFH’s HMIS Notice reporting of Privacy Practices documentaggregate and to entities that provide funding to this agency. The San Diego County CoC HMIS Lead Agency and this agency are hereby released from any legal responsibility or liability for the release, use or disclosure of information I previously authorized. Client Name Date of Birth Social Security Number Client Signature Date Agency Staff Agency Staff Signature Agency Name Date San Diego County CoC Homeless Management Information System (HMIS) How to File a Privacy Complaint If you feel that a violation of your rights as an HMIS client has occurred, or if you disagree with a decision that has been made about your Protected HMIS Information, you may complete this form and submit to the HMIS Lead Agency, the Regional Taskforce on the Homeless. Please complete this form only after you have exhausted the grievance procedures for the agency providing you housing and/or services. It is against the law for any agency to take retaliatory action against you if you file this grievance. You can expect a response within 30 (thirty) days via the grievance method of your choice. Grievances must be submitted in writing to: Regional Taskforce on the Homeless 0000 Xxxxxx Xxxxxx Rd. San Diego, CA 92123 Brief Description of grievance (what happened): Date(s) of offense(s) Name of Individual(s) who violated your rights Name of Agency(ies) who violated your rights Your Contact Information Your Name Phone Number and/or Email Address Mailing Address Today’s Date HMIS Lead Agency Use Only Response Date Recommendation to Agency San Diego County CoC Homeless Management Information System (HMIS) HMIS Privacy Grievance Procedure Page 1 of 1 Policies and Procedures Legal Framework

MANDATORY COLLECTION NOTICE. We collect personal information directly from you for reasons that are discussed in our privacy statement. We may be required to collect some personal information as mandated by law or as requested from entities that fund this program. Other personal information we collect is necessary to operate programs, improve services, and better understand homelessness. We collect appropriate information only. A Privacy Notice is available upon request. APPENDIX G: Client Revocation of Multiparty Authorization to Use and/or Disclose Information‌ San Diego County CoC Homeless Management Information System (HMIS) Client Revocation of Authorization to Release Information I, , hereby revoke permission for this agency to share my personal information in the San Diego County CoC Homeless Management Information System (HMIS) and also revoke my permission to share my data to the Community Information Exchange (CIE). I understand that my information will remain in HMIS as part of the non-identifying data collected on homeless services provided by the San Diego County Continuum of Care (CoC) and I understand that my information will only be used according to the procedures outlined in the RTFH’s HMIS Notice of Privacy Practices document. I understand that information that has already been entered will remain in the system. By canceling my agreement for sharing information within the HMIS, my personal information that has been saved will be restricted. I further understand that this revocation of data sharing only applies to information within the HMIS. Any information which was shared or retained outside of HMIS is not affected by this revocation. By signing, I acknowledge and understand that this Client Revocation of Consent to Release Information applies only to the sharing of information within the HMIS from this day forward. I also understand that the disclosure of my non-identifying information may be required in some instances which are outlined in the RTFH’s HMIS Notice of Privacy Practices document. The San Diego County CoC HMIS Lead Agency and this agency are hereby released from any legal responsibility or liability for the release, use or disclosure of information I previously authorized. Client Name Date of Birth Social Security Number Client Signature Date Agency Staff Agency Staff Signature Agency Name Date San Diego County CoC Homeless Management Information System (HMIS) HMIS)‌ How to File a Privacy Complaint If you feel that a violation of your rights as an HMIS client has occurred, or if you disagree with a decision that has been made about your Protected HMIS Information, you may complete this form and submit to the HMIS Lead Agency, the Regional Taskforce on the Homeless. Please complete this form only after you have exhausted the grievance procedures for the agency providing you housing and/or services. It is against the law for any agency to take retaliatory action against you if you file this grievance. You can expect a response within 30 (thirty) days via the grievance method of your choice. Grievances must be submitted in writing to: Regional Taskforce on the Homeless 0000 Xxxxxx Xxxxxx Rd. San Diego, CA 92123 Brief Description of grievance (what happened): Date(s) of offense(s) Name of Individual(s) who violated your rights Name of Agency(ies) who violated your rights Your Contact Information Your Name Phone Number and/or Email Address Mailing Address Today’s Date HMIS Lead Agency Use Only Response Date Recommendation to Agency San Diego County CoC HMIS Privacy Grievance Procedure Page 1 of 1 San Diego County CoC Homeless Management Information System (HMIS) HMIS)‌ Policies and Procedures Legal Framework