By signing this agreement, you give consent to disclose and share personally identifiable information on the person listed below with authorized partners in the Delta Health Alliance. The purpose of sharing this information is to allow the Delta Health Alliance to recruit and provide well-informed, coordinated services to participants and their families, to conduct ongoing evaluation and improvement of programs to better serve the community, and to report results of programs and activities to participants, residents, partners, and funders.
The Delta Health Alliance takes every precaution to protect personally identifiable information from unauthorized use or disclosure. Information obtained on persons shall not be published in a manner that will lead to the identification of any individual. This information is used solely for service provision and program evaluation purposes and identified information shall not be further redisclosed to third parties not covered by this Consent Agreement without your prior written consent.
I understand that the records to be disclosed and shared with Delta Health Alliance may include but are not limited to:
Education records, including:
- Enrollment information
- Classroom performance and behavior
- Performance on state of MS Core Curriculum Assessments and other standardized assessments
- Grade reports
- Transcripts
- Attendance
- Survey data
- Program of study
- Internship/apprenticeship performance appraisal and Certification examination results
Records from Delta Health Alliance Service Providers, including:
- Intake information collected on participants (such as name, address, and date of birth)
- Participation data (such as services received, attendance dates, and length of time participating)
- Program results and assessments (such as test results and observations by program staff)
- Program results and assessments (such as test results and observations by program staff)
Photographs:
- Use of photography in any Delta Health Alliance publication or advertising materials. All rights of privacy or compensation, which may be in connection with use of the photograph are waived.
Furthermore I consent that the following parties may obtain the information described above stripped of any and all direct identifiers:
- The U.S. Department of Education and its authorized contractor(s).
- The DHA external evaluators and its team of authorized researcher(s).
For up to date information and questions, please contact Delta Health Alliance at:
Delta Health Alliance
435 Stoneville Road
Stoneville, MS 38776
Phone (662)-686-7004
Delta Health Alliance authorized partners:
- North Bolivar Consolidated School District
- Greenville Public School District
- National Strategic Planning and Research Center
- University of Memphis
- Monsanto Company
- Leland Medical Clinic
- Mississippi Delta Community College
- Coahoma Community College
I have read, and understood and accepted the above statements:
I hereby give my consent to release information as deemed beneficial to me and/or my family and will be an active participant in the process. This Consent Agreement is valid as long as I receive service provisions from Delta Health Alliance. Until such time as I withdraw my consent, which must be communicated in writing and addressed to Delta Health Alliance my consent shall remain in place, valid and effective. I have a right to receive a copy of this document. I reserve all rights provided to me by law not waived by the scope of this consent and authorization.
