NV_CPS_ICF_Final

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF CHILD AND FAMILY SERVICES

Consent/Authorization for Release of Information from the Division of Child and Family Services

Related to the MIHOPE Study

To be completed by the person giving consent/authorization (please print). This information is being requested solely to verify the identity of the person giving consent/authorization.

NAME(s):_________________________________________________________________________________________________

(include any other names by which you have been known)

DATE OF BIRTH:__________________________________ SS# (optional)____________________________________________

CURRENT ADDRESS:_____________________________________CITY, STATE, ZIP_________________________________

NEVADA ADDRESS(ES):___________________________________________________________________________________

(City, State, Zip for each)

_________________________________________________________________________________________________________

Authorization/Consent: I authorize the Nevada Division of Child and Family Services to release all records it maintains regarding reports of maltreatment involving physical abuse or neglect of minors, including those in which I am named as the person found responsible for the minor.

The information will be released to:

NAME:__MDRC_________________________________ AGENCY:__________________________________________________

ADDRESS:__16 East 34^th street___________________ CITY, STATE, ZIP__New York, NY 10016________________

PHONE #:___212-340-8863_____________ FAX #:___212-532-8453______________________

This information will be used for: _The data will be used by the Mother and Infant Home Visiting Program Evaluation_____

Consequences:

I know that state and federal privacy laws protect my records. I know:

• Why I am being asked to release this information;

• I do not have to consent to the release of this information;

• That, generally, I must give my written consent for the Nevada Division of Child and Family Services to give out the information;

• The person or agency who gets my information may be able to pass it on to others;

• If I do not consent, the information will not be released unless the law otherwise allows it;

• I may stop this consent with a written notice at any time, but this written notice will not affect information the agency has already released;

• This consent will end at the end of the MIHOPE study.

________________________________________________________ DATE:____________________________________________

Individual’s Signature

________________________________________________________ DATE: ___________________________________________

Parent/Guardian/Authorized Representative (if individual is a minor)

4126 Technology Way, 3^rd Floor  Carson City, Nevada  89706

http://www.dcfs.state.nv.us/