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VDSS Data Sharing Consent Form
VDSS Data Sharing Consent Form

VDSS Data Sharing Consent Form

Post-Adoption Services Data Sharing Consent

Family Name(Required)
Case Manager Name

Data Sharing with the Virginia Department of Social Services

The post-adoption support program is funded through a generous grant from the Virginia Department of Social Services (VDSS). As funders of our program, VDSS is asking your consent for us to share certain personal data with their organization. VDSS will use this data to evaluate contract performance and to conduct research on outcomes for recipients of services. All data that is shared will be protected as required by state and federal law. Additionally, consent can be withdrawn at any time by contacting RPACSconsent@depaulcr.org.

PLEASE KNOW THAT SHARING YOUR DATA IS OPTIONAL AND THAT SERVICES WILL NOT BE WITHHELD IF YOU DECLINE TO SHARE YOUR INFORMATION.

VDSS is requesting the following data for each household member:

  • First name
  • Last name
  • Date of Birth
  • Social Security Number
  • Race
  • Home address
  • Adoptive parent email address
  • Services received (case management, peer support, mental health, training/education, crisis support)
  • Date of service
  • Location of service

Consent

*A CONSENT FORM MUST BE COMPLETED FOR EACH PARENT*
My family consents/declines to have their data shared with the Virginia Department of Social Services(Required)

Consent For Adopted Children

*ONLY ONE PARENT NEEDS TO PROVIDE CONSENT FOR THE ADOPTED CHILDREN IN THE HOME. INFORMATION FOR BIOLOGICAL CHILDREN DOES NOT NEED TO BE INCLUDED*

DePaul Community Resources has consent to share the personal data of family members listed below, with the Virginia Department of Social Services:

Signature of Person Completing This Form