DRAFT (8/l0/0l)
| |NH WORKS System Partners |
| |Release of Information |
| | |
| | |
| | |
|NH Employment Security | |
| | |
|NH Department of Education | |
|- Adult Education | |
|- Vocational Education | |
|- Vocational Rehabilitation | |
| | |
|NH Department of Health and Human | |
|Services | |
| | |
|Department of | |
|Resources and | |
|Economic Development | |
|Office of Workforce Opportunity | |
| | |
|New England Farmworker Council | |
|- Migrant & Seasonal | |
|Farmworker Program | |
| | |
|Community College | |
|System of New Hampshire | |
| |I, | |, authorize |
| | | to exchange |
| | |
| |information relating to prior assessment(s) for training and employment including work history, |
| |quarterly wage data, and Unemployment |
| |Compensation benefits with | |. |
| |This Release of Information does not authorize the disclosure of any medical information or any other |
| |restricted third party information. |
| | |
| |I understand that this information will be used to determine eligibility for employment and training |
| |services, will assist in the development of my individual training plan for education and/or employment, and|
| |will be used for statistical purposes. |
| | |
| |I allow the NH Works System Partners identified to release to each other the requested information when I am|
| |referred to partner services. I understand the information will be used only on an as needed basis and will|
| |remain confidential, to the extent required and/or permitted by law. This information cannot be shared with|
| |any other entity without my written permission. |
| | |
| |A copy of this Release of Information is as valid as the original. This Release is valid for both program |
| |and follow-up services. |
| | |
| |_________________________________________________________ |
| |Participant’s Signature Date |
| | |
| |_________________________________ |
| |Guardian’s Signature if applicable |
| | |
| |_________________________________ __________________________ |
| |Staff Signature Email Address |
NH WORKS One-Stop Partner Agencies are Equal Opportunity Employers.
Auxiliary aids and services are available upon request to individuals with disabilities. TDD ACCESS: RELAY NH 1-800-735-2964
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NHES 0350
N-2/13
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