Memorandum of Understanding Template 2012

Memorandum of Understanding Template 2012

Memorandum of Agreement

This is a Memorandum of Agreement between Local Agency A (XXXXX) and Local Agency B (XXXXX) and the Arizona Living Well Institute.

I. Purpose and Scope

The purpose of this Memorandum of Agreement (MOA) is to acknowledge the partnership between XXXXX and XXXXX and the Arizona Living Well Institute,and clearly identify the roles and responsibilities of each party as they relate to providing evidence based programming, specifically the Healthy Livingand Tomando Control Workshops in X Region in Arizona.

The Health Living and Tomando Control Workshops, also known as Stanford Chronic Disease Self-Management Program, is a six-week self-management workshop for people with chronic health conditions and the caregivers of those with a chronic condition. The workshop was created by and is licensed through the Stanford Patient Education Research Center. Healthy Living is the English version and Tomando Control is the Spanish version.

To ensure the fidelity of the program, XXXXX and XXXXX and the Arizona Living Well Institute agree to implement the workshop with fidelity as stated in the Stanford 1) Chronic Disease Self-Management Program Lay Leader’s Manual, 2) Implementation Manual, and the 3) Fidelity Manual.

II. MOA Term

The term of this MOA Agreement is the period within which the project mutual responsibilities shall be performed. The term commences on (MM/DD/YYYY)and terminates on (MM/DD/YYYY).

III. YCCHS and NACOG Agree to the Following Provisions:

  1. To participate in annual planning for dissemination of Health Living Workshops in X Region of Arizona. This may include targeting underserved rural communities, training facilitators, and recruiting participants.
  • Both agencies may agree to co-sponsor Leader training in which case both agencies share the responsibilities of providing materials, space, staffing, marketing materials and other training supplies as needed.
  • Both agencies agree to follow-up with any Leader trainees from partner agencies who attend training, this may include fidelity coaching, technical assistance, or support as needed. Follow-up responsibilities with a particular agency or trainee will be agreed upon by XXXXX and XXXXX prior to training.
  1. Each agency will maintain a current point of contact for Healthy Living activities.
  2. To maintain regular communication on at least a monthly basis. This can be done through phone calls, teleconference, e-mail or face-to-facemeetings.
  3. To keep each other informed of current and future workshops and provide support in the form of marketing and/or providing facilitators as available.
  4. Notify each partner agency of any fidelity issues observed during training or facilitation of workshops.
  5. Maintain at least 2 individuals affiliated with the agency to facilitate the dissemination and sustainability of Healthy Living workshops over time.
  • One individual with functional administrative understanding of the program and
  • One who is trained and can deliver Healthy Living workshops.The workshop leader may be agency staff, a volunteer, contractor or agency partner.
  1. One organization will be designated to:
  2. Complete the Workshop Information Form on the Arizona Living Well Institute ( 4-6 weeks prior to the start of the workshop and
  3. Return the completed workshop survey packet to the Arizona Living Well Institute within 2 weeks of completion of the workshop.

*During a joint meeting each partner agency will identify what responsibilities are appropriate for inclusion in this MOA.

IV. XXXXX Responsibilities:

XXXXXshall undertake the following activities during the duration of the MOA term:

Examples of responsibilities are included but are not limited to:

  1. Joint purchasing of workshop materials.
  2. In-kind materials exchange
  3. What role in training follow-up, coaching, support and TA for partner organizations
  4. What role in fidelity check-ups and plan of action.
  5. What role in ongoing partner communication and coordination.
  6. Identifying lead for particular Healthy Living program components related to marketing, referrals, training, etc.

V.XXXXXResponsibilities:

XXXXXshall undertake the following activities during the duration of the MOA term:

Examplesof responsibilities are included but are not limited to:

  1. Joint purchasing of workshop materials.
  2. In-kind materials exchange
  3. What role in training follow-up, coaching, support and TA for partner organizations
  4. What role in fidelity check-ups and plan of action.
  5. What role in ongoing partner communication and coordination.
  6. Identifying lead for particular Healthy Living program components related to marketing, referrals, training, etc.

VI. Arizona Living Well Institute Responsibilities:

Arizona Living Well Instituteshall undertake the following activities during the duration of the MOA term:

  1. Provide license space for a predetermined number of workshops annually (Healthy Living and/or Tomando Control)
  2. Provide copies of survey packets as requested on the Workshop Information Form (
  3. Complete data entry and management for all survey packets returned to the Arizona Living Well Institute.

VII. Effective Date and Signature

This MOA shall be effective upon the signature of

IN WITNESS WHEROF, the above and below listed agencies have executed this agreement consisting of four (4) pages.

Partner Name and Address:Partner Name & Address:

XXXXX AgencyXXXXX Agency

Street AddressStreet Address

City, AZ XXXXXCity, AZ XXXXX

Programmatic Signatory Authority Programmatic Signatory Authority

______

Date______Date______

Partner Name & Address:

Arizona Living Well Institute

2066 W Apache Trail, Ste. 116

Apache Junction, AZ 85120

Programmatic Signatory Authority

Date______

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