AUTHORIZATION TO SHARE CONFIDENTIAL INFORMATION AND CONSENT TO PARTICIPATE IN THE STATEWIDE EVALUATION OF FIRST 5 CALIFORNIA AND THE LOCAL EVALUATION OF FIRST 5 MADERA COUNTY
The Exceptional Parents Unlimited (EPU) receives funding from First 5 Madera County, which mandates that programs be evaluated, so that funding decisions are based on their results. The purpose of the evaluation is to learn how programs help children to be ready to learn and do well at school. Under this mandate, First 5 Madera County is conducting a local evaluation of the programs funded by Proposition 10 in Madera County. First 5 Madera County will use the findings of the evaluation in its policy decisions. The information collected for evaluation will also be shared with the First 5 California evaluation staff.
Exceptional Parents Unlimited (epu) staff will record the program activities I participate in, and ask me a few questions at relevant points of the program. I will be asked information such as my name birth date, birth place, gender, current address, race and ethnicity, languages spoken, etc.
Only certain Exceptional Parents Unlimited(EPU) staff members, First 5 California evaluation staff, the First 5 Madera County evaluation team, and the First 5 Madera County Commission will be allowed to see my personal information. These people cannot share this information with anyone, unless they believe I may be in danger of being hurt or be a danger to someone else.
It is very important to this program that my private information is safe. Therefore, my information will be protected by the strictest security measures, to respect my confidentiality rights. State and federal laws protect the personal and health information I share, even if the Federal Privacy Role does not do so.
Local and First 5 California evaluators and staff will use my information, without names or identifying information, to learn what activities and programs are most useful for children and families. The local evaluation team will not be provided with personal information that could identify me personally, such as name or address. Reports will not have personal information in them. In addition, information about drug or alcohol abuse, or any criminal arrests or convictions, will not be shared with the evaluation team. The evaluators will keep all information in a manner that ensures the maximum protection of privacy and confidentiality rights. Taking part in this evaluation involves very little known risk to me or my family.
I understand that this authorization is voluntary, and will end in ten (10) years from the date on this form. If I choose not to participate in the evaluation, I will still receive services from this program. If I choose to participate, I can always change my mind and ask that my information no longer be shared, or that it be erased. I can do this by filling out a form, available at this program. If I am a minor, I can cancel this authorization in writing when I become a legal adult.
Please check the relevant box below:
I agree to allow the Exceptional Parents Unlimited (EPU) to share information about me with First 5 California evaluation staff, the First 5 Madera County evaluation team, and the First 5 Madera County Commission.
I do not agree to participate in the local evaluation of First 5 Madera County and the First 5 California State evaluation.
I agree with the terms above and acknowledge that I have been given a copy of the consent form. I understand that additional questions regarding this form or my rights should be directed to one of the following:
Christina Sauceda, Program Officer-EvaluationChinayera C. Black-Hardman, Executive Director
First 5 Madera CountyFirst 5 Madera County
525 E. Yosemite Avenue 525 E. Yosemite Avenue
Madera, CA 93638 Madera, Ca 93638
Phone: (559) 661-5155Phone: (559) 661-5155
Email: mail:
Signature of the Participant Date
Name of the Participant
IF MINOR:
Signature of the Legal Guardian Date
Name of the Legal Guardian Relation to Child
Signature of Staff Member Date
Name of the Staff MemberAGENCY