Verbal Acknowledgement
Data Collection and Consent to ShareThis agency would like permission to collect your personal identifying information (i.e. birthdate, social security number, photo I.D., etc.) to see what programs you qualify for and to better serve you. This acknowledgment expires in one year. Your information will be entered into the Choose an item. database. Data collection helps us to maintain this program and others like it. People who work for this agency and other similar agencies in the state request the use of your information to help provide services to you. If you allow us to securely share your data, you may change your mind and cancel this consent at any time. Persons and groups listed on the privacy notice may see your information in Choose an item., even if you tell us we cannot share. 319976570294500*IF* diversion is unsuccessful, a parent or legal guardian must list ALL children under 18 in the household on the back of this form.Verbal AcknowledgementThe use of verbal consent for data collection is authorized only when completing diversion assessment and referral by phone for the purposes of coordinated entry into Choose an item.. The agency representative who directly received verbal consent from the participant must be the one to sign this form. Agree Disagree Participant Name (printed)Agency RepresentativeSignature and Date//3114675596201500In-Person Acknowledgement Agree DisagreeParticipant Name (printed)Participant Signature and Date//Agency RepresentativeSignature and Date//312420041910000In-Person Acknowledgment of Data Collection & Consent to Share for minors in the household152400825500As the parent or legal guardian of the child/children listed below, I confirm that the child’s/children’s data should be treated the same as my own. Agree DisagreeChild’s NameChild’s Date of Birth//////// ................
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