Tchccochmis System ETO Tchc.Etosoftware.Com

ClientConsentofDataCollectionForm

TCHCCoCHMIS System“ETO”tchc.etosoftware.com

I,

(Client’sname),understandand

acknowledgethat(Agencyname)isaffiliatedwiththeTCHCCoCHMISSystem“ETO”,andIconsenttoandauthorizethecollectionofinformationandpreparationofrecordspertainingtotheservicesprovidedtomebytheAgency.TheinformationgatheredandpreparedbytheAgencywillbeincludedinaHomelessManagementInformationSystem(“HMIS”)databaseandshallbeusedbytheAgency,TCHCandtheU.S.DepartmentofHousingandUrbanDevelopment (HUD)to:

• Help usprioritize,plan,andprovide meaningfulservicestoyouandyourfamily;
• Assist our agencytoimprove itsworkwithfamiliesandindividualsthatare homeless;
• Allowlocalagenciestoworkbettertogethertopreventand endhomelessness;
• Providestatisticsfor local, state,andnationalpolicymakerstoseteffectivegoals.

IunderstandthatthefollowingHUD-mandatedUniversalDataElementswillbecollectedforthepurposesofunduplicatedestimatesofthe numberof homelesspeopleaccessingservicesfromhomelessproviders,basicdemographiccharacteristicsofpeoplewhoarehomeless,andtheirpatternsofserviceuse.

1.Name

2.SocialSecurityNumber

3.DateofBirth

4.Ethnicityand Race

5.Gender

6.VeteranStatus

7.DisablingCondition

8.ResidencePriortoProgramEntry

9.Zip Codeof LastPermanentAddress

10.ProgramEntryDate

11.ProgramExitDate

12.UniquePersonIdentificationNumber*

13.ProgramIdentificationNumber*

14.HouseholdIdentificationNumber*

*ETOSystemGeneratedNumbers

IalsounderstandthatthefollowingProgram-SpecificDataElementswillbecollectedforprogramsthatarerequiredtoreporttoHUD,theCityofFortWorth,CityofArlingtonandTarrantCounty,theStateofTexasandtheUnitedWay.ProgramsandagencieswithoutthisreportingrequirementmayalsocollecttheseelementstofacilitateabetterunderstandingofthehomelesspopulationinTarrantandParkercounties.

1.Incomeand Sources

2.Non-CashBenefits

3.PhysicalDisability

4.DevelopmentalDisability

5.HIV/AIDS

6.MentalHealth

7.SubstanceAbuse

8.DomesticViolence

9.ServicesReceived

10.Destination

11.ReasonsforLeaving

12.Employment

13.Education

14.GeneralHealthStatus

15.PregnancyStatus

16.Veteran’sInformation

17.Children’sEducation

IunderstandthatIhavetherighttoinspect,copy,andrequestallrecordsmaintainedbytheAgencyrelatingtotheprovisionof servicestome andtoreceive apaper copyofthisform.

Iunderstandthatmyrecordsareprotectedbyfederal,state,andlocalregulationsgoverningconfidentialityofclientrecordsandcannotbedisclosedtoany otherentityexcepttheAgency,TCHCandHUDwithoutmywrittenconsentunlessotherwise provided for in the regulations.

Additionally,Iunderstandthatparticipationindatacollectionisoptional,andIamabletoaccessshelter andhousingservicesif Ichoosenottoparticipate indata collection.

Signature:

Date:

Relationshipifminor

Person administeringthisConsentForm:(printclearly)

Name:

AgencyName:

ClientReleaseofInformationConsentForm

TCHCCoCHMIS System“ETO”tchc.etosoftware.com

ClientName:HMISID#:

ThisAgency,permittedbyyou,theclient,hastheabilitytoshareyourinformationcontainedintheTCHCCoCHMISwithotherparticipatingagencies.Thissharingofinformationmayenableagenciestobetterserveyou.Ifyou,theclient,authorizesthissharingofinformationpleasecompletethefollowing.

I,

(Client’sname)herebyauthorize

(Agency name)toreleasethefollowingpersonalinformationcontainedintheTCHCCoCHMISSystem“ETO”totheagencieslistedontheattachment(ROI–Attachment A).

Ireleasethe abovenamedAgencyofanylegal liabilitythat mayarisefrom thereleaseofthisinformation.Iunderstand thattheAgencycannot releaseinformationobtainedfromothersources.Iunderstandthattheagency(ies)receivingthisinformation cannotre-releasethisinformationtoanyotheragency(ies)withoutmyexpressedwrittenconsent.Ialsounderstand thatthisauthorizationforreleaseofinformationwill expire on / / (Recommendedtwoyearfromenrollmentdate:MM/DD/YYYY.)unlessotherwiseindicated.

Ialso understandthatthisrelease canbe revoked, bymeatanytime andthattherevocationmustbesignedanddatedbyme,andthatrevokingofthereleasewillnotaffectinformationreleasedpriortotherevokingoftherelease.

Signature

Date

Relationshipifminor

WitnessName(Print)

WitnessSignature

Date

ClientConsenttoCollectCriticalDocuments

TCHCCoCHMIS System“ETO”tchc.etosoftware.com

I,

(Client’sname),understandand

acknowledgethat(Agencyname)isaffiliatedwiththeContinuumofCareTX601(CoC)HMISSystem“ETO”,andIconsenttoandauthorizetherequesttocollectofcopiesofcriticaldocumentsandvitalrecordsbytheAgency.ThedocumentsgatheredwillbeincludedintheHomelessManagementInformationSystem(“HMIS”)databaseandshallbeusedbyCoCAgenciesto:

• Provideanelectronicstoragelocationforcopiesofcriticaldocumentsandvitalrecordsandallowtheclienttoaccesscopiesofcriticaldocumentsthatmaybelost,stolen,orneededforproofofidentityor reapplicationfor criticaldocumentsand vitalrecords,and
• Assist intheapplicationand/ortodetermineeligibilityforprogramsand services.

RecordsthatIconsentto be copied, scannedandattachedto myHMIS ClientRecordinclude:(Checkall thatapply):

StateIdentification/DriversLicense

BirthCertificate

Social SecurityCard

BirthCertificate

Medicaid/MedicareorotherHealthInsuranceCard

VoterRegistrationCard

VeteranStatus/MilitaryID/DD214

DischargeDocuments(ex:Prison,Hospital,FosterCare,etc.)

ProofofIncome

AwardLetters(SSI/SSDI,VADisability,etc.)

Hard Copyof HUDAssessments

Other

MinorChildrenwithinthe HouseholdIncludedinthis Consent:

(Ifapplicable)

Name:Dateof Birth:

Name:Dateof Birth:

Name:Dateof Birth:

Name:Dateof Birth:

Name:Dateof Birth:

IunderstandthatIhavetherighttoinspect,copy,andrequestallrecordsmaintainedbytheAgencywithintheHMISsystemrelatingtotheprovisionofservicestomeandto receiveapapercopy ofthisform.

Iunderstandthatmyrecordsareprotectedbyfederal,state,andlocalregulationsgoverningconfidentialityofclientrecordsandcannotbedisclosedtoany otherentitywithoutmywritten consentunlessotherwise provided for in the regulations.

Additionally,Iunderstandthatparticipationinthiscriticaldocumentsandvitalrecordscollectionisoptional.

Signature:

Date:

Relationshipifminor

Person administeringthisConsentForm:(printclearly)

Name:

AgencyName: