Att 6_Agreement for Cross-Jurisdictional

Attachment 6
Agreement for Cross-Jurisdictional Data Collection
Medical Monitoring Project
0920-0740

Agreement for Cross-Jurisdictional Data Collection by the Medical Monitoring Project
Name of State, District, or Territorial Health Department: ________________________________________________
As the Overall Responsible Party (ORP) for my jurisdiction, I ask that the following guidance be observed when conducting Medical
Monitoring Project (MMP) cross-jurisdictional interviews or medical record requests by remote means such as telephone, mail, or
secure fax, including those for the Case-Surveillance-Based Sampling Demonstration Project, involving persons sampled from case
surveillance records in another jurisdiction who currently reside in my jurisdiction:
My jurisdiction grants approval for this activity without notification. The jurisdiction of sampling is permitted to
contact, recruit, and interview persons residing in my jurisdiction at-will. We request to not be notified of CSBS
activities in this jurisdiction.
My jurisdiction grants approval for this activity with prompt notification following recruitment. The jurisdiction
of sampling will notify my jurisdiction’s HIV Surveillance Coordinator or designee of encounters with sampled
persons residing in my jurisdiction within 3 business days. I understand that, in some uncommon instances, the
jurisdiction will not be legally allowed to disclose the name of the person, and notification of the encounter
without name disclosure is sufficient in these instances.
My jurisdiction grants approval for this activity with notification prior to recruitment. Once notified of plans to
recruit someone in my jurisdiction, my jurisdiction’s HIV Surveillance Coordinator or designee may deny
recruitment of any such persons by making this request of the jurisdiction of sampling within 5 business days of
initial notification. I recognize that in some cases the jurisdiction of sampling may unintentionally contact a person
residing in my jurisdiction, e.g. by dialing a telephone number. In such cases, the sampled person may immediately
be given the opportunity to interview out of respect for the person’s time. However, my jurisdiction will be
notified of the encounter with this sampled person by name and asked for permission to contact medical facilities
for access to medical records (if applicable) within 3 business days. If I select this option, jurisdictions not legally
allowed to disclose the name of the contacted person to my jurisdiction will not be allowed to conduct this activity
in my jurisdiction.
My jurisdiction refuses all MMP cross-jurisdictional data collection on sampled residents that have moved into
my jurisdiction.
Cross-jurisdictional medical record abstraction will only be conducted with a signed medical record release from the patient using
methods that comply with all National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention security and confidentiality
guidelines such as mail or secure fax. None of the options above imply permission to physically enter my jurisdiction for the purpose
of cross-jurisdictional data collection without additional permission. Jurisdictions of sampling are required to assist my jurisdiction by
providing any information to enhance case surveillance that they may legally provide. The point of contact for MMP crossjurisdictional activities, including facilitation of case surveillance reporting to my jurisdiction as well as linkage and re-engagement
services, is:
_______________________________ ____________________ ____________________

____________________

Name of point of contact/designee

Email address

Title

Telephone number

This agreement will be honored by the Medical Monitoring Project until amended by my jurisdiction in writing.
_______________________________

______________________________

___________________________

Signature of ORP

Signature of Surveillance Coordinator

Third Signature (optional)

_______________________________

______________________________

___________________________

Name of ORP

Name of Surveillance Coordinator

Name & Title of Third Signatory

_______________________________

______________________________

___________________________

Date

Date

Date

Please return this completed agreement to the MMP team c/o Dr. Linda Beer at [email protected] or telephone 404-639-5268.