"Memorandum of Understanding - Disclosure Agreement for Information With Other Programs" - Arizona

Memorandum of Understanding - Disclosure Agreement for Information With Other Programs is a legal document that was released by the Arizona Department of Education - a government authority operating within Arizona.

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MEMORANDUM OF UNDERSTANDING
DI SC O L SU R E AG R E E M ENT FO R IN FO R M A TIO N WI TH O T HE R P RO G R A M S
1. Purpose and Scope
[Insert name of determining agency]
and
[Insert name of receiving agency]
acknowledge and agree
that children’s free and reduced price meal and free milk eligibility information obtained under provisions
of the National School Lunch Act (42 U.S.C. 1751 et seq.) or Child Nutrition Act of 1966 (42 U.S.C. 1771
et seq.) and the regulations implementing those Acts is confidential information. This Memorandum of
Understanding (MOU) is intended to ensure that any information disclosed by
[Insert name of
determining agency]
to the
[Insert name of receiving agency]
about children eligible for free and
reduced price meals or free milk will be used only for purposes specified in this MOU and that
[Insert
name of determining agency]
and
[Insert name of receiving agency]
recognize that there are
penalties for unauthorized disclosures of this eligibility information.
2. Authority
Section 9(b)(2)(C)(iii) of the National School Lunch Act (42 U.S.C. 1758(b)(2)(C)(iii)) authorizes the limited
disclosure of children’s free and reduced price meal or free milk eligibility information to specific programs
or individuals, without prior parent/guardian consent. Except that, the parent/guardian must be provided
the opportunity to decline to share eligibility information prior to the disclosure for identifying children
eligible for benefits under or enrolling children in the State Medicaid and Kidscare program. Additionally,
the statute specifies that for any disclosures not authorized by the statute, the consent of children’s
parents/guardians must be obtained prior to the disclosure. For any unauthorized disclosure of children’s
eligibility information, the statute specifies a fine of not more than $1,000 or imprisonment of not more
than 1 year or both.
3. Responsibilities
[Insert name of determining agency]
will:
determine children’s free and reduced price meal or free milk eligibility in accordance with the
income eligibility criteria mandated by the Department of Agriculture;
inform households that their children’s free and reduced price meal or free milk eligibility
information may be shared;
notify parent/guardian of potential disclosures and provide opportunity for parents/guardians to
elect not to have information disclosed to State Medicaid and Kidscare;
disclose eligibility information only to persons directly connected to the administration or
enforcement of programs authorized access under the National School Lunch Act or regulations
under the Act or to programs or services for which parents/guardians gave consent;
include a Privacy Act statement when necessary and ensure the statement meets the Privacy Act
requirements;
secure parent/guardian consent prior to any disclosure not authorized by the National School
Lunch Act or any regulations under that Act and disclose eligibility information only to those
persons directly connected to programs for which prior consent was given.
MEMORANDUM OF UNDERSTANDING
DI SC O L SU R E AG R E E M ENT FO R IN FO R M A TIO N WI TH O T HE R P RO G R A M S
1. Purpose and Scope
[Insert name of determining agency]
and
[Insert name of receiving agency]
acknowledge and agree
that children’s free and reduced price meal and free milk eligibility information obtained under provisions
of the National School Lunch Act (42 U.S.C. 1751 et seq.) or Child Nutrition Act of 1966 (42 U.S.C. 1771
et seq.) and the regulations implementing those Acts is confidential information. This Memorandum of
Understanding (MOU) is intended to ensure that any information disclosed by
[Insert name of
determining agency]
to the
[Insert name of receiving agency]
about children eligible for free and
reduced price meals or free milk will be used only for purposes specified in this MOU and that
[Insert
name of determining agency]
and
[Insert name of receiving agency]
recognize that there are
penalties for unauthorized disclosures of this eligibility information.
2. Authority
Section 9(b)(2)(C)(iii) of the National School Lunch Act (42 U.S.C. 1758(b)(2)(C)(iii)) authorizes the limited
disclosure of children’s free and reduced price meal or free milk eligibility information to specific programs
or individuals, without prior parent/guardian consent. Except that, the parent/guardian must be provided
the opportunity to decline to share eligibility information prior to the disclosure for identifying children
eligible for benefits under or enrolling children in the State Medicaid and Kidscare program. Additionally,
the statute specifies that for any disclosures not authorized by the statute, the consent of children’s
parents/guardians must be obtained prior to the disclosure. For any unauthorized disclosure of children’s
eligibility information, the statute specifies a fine of not more than $1,000 or imprisonment of not more
than 1 year or both.
3. Responsibilities
[Insert name of determining agency]
will:
determine children’s free and reduced price meal or free milk eligibility in accordance with the
income eligibility criteria mandated by the Department of Agriculture;
inform households that their children’s free and reduced price meal or free milk eligibility
information may be shared;
notify parent/guardian of potential disclosures and provide opportunity for parents/guardians to
elect not to have information disclosed to State Medicaid and Kidscare;
disclose eligibility information only to persons directly connected to the administration or
enforcement of programs authorized access under the National School Lunch Act or regulations
under the Act or to programs or services for which parents/guardians gave consent;
include a Privacy Act statement when necessary and ensure the statement meets the Privacy Act
requirements;
secure parent/guardian consent prior to any disclosure not authorized by the National School
Lunch Act or any regulations under that Act and disclose eligibility information only to those
persons directly connected to programs for which prior consent was given.
[Insert name of receiving agency]
will:
Ensure that only persons who are directly connected with the administration or enforcement of the
[Insert
name of the program]
and whose job responsibilities require use of the eligibility information will have
access to children’s eligibility information.
Specify name(s) and/or title(s).
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________
Use children’s free and reduced price eligibility information for the following specific purpose(s):
Describe
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
__________________________________________
Inform all persons that have access to children’s free and reduced price meal or free milk eligibility
information that the information is confidential and must be used only for purposes specified above;
Protect the confidentiality of children’s free and reduced price meal or free milk eligibility information as
follows:
Specifically describe how the information will be protected from unauthorized uses and further
disclosures.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Implement the following procedures for transferring meal eligibility information (may be completed by
either the determining agency or receiving agency).
Describe the procedures for transferring students’ meal eligibility information from the
determining agency to the requesting agency/program so as to limit the number of individuals
who have access to the information.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Effective Dates
This agreement shall be effective from ______________________ to ______________________.
5. Penalties
Any person who publishes, divulges, discloses, or makes known in any manner, or to any extent not
authorized by Federal law (Section 9(b)(2)(C) of the National School Lunch Act; 42 U.S.C. 1758 (b)(2)(C))
or a regulation, any information about a child’s eligibility for free and reduced price meals or free milk shall
be fined not more than a $1,000 or imprisonment of not more than 1 year or both.
6. Signatures
The parties acknowledge that children’s free and reduced price meal and free milk eligibility information
may be used only for the specific purposes stated above and that unauthorized use of free and reduced
price meal and free milk information or further disclosure to other persons is prohibited and a violation of
Federal law which may result in civil and criminal penalties.
Receiving Agency Representative
Date
Determining Agency Representative
Date
Sincerely,
[signature]
[name]
[phone number] [e-mail address]
The Richard B. Russell National School Lunch Act requires the information requested in order to verify
your children’s eligibility for free or reduced-price meals. If you do not provide the information or provide
incomplete information, your children may no longer receive free or reduced-price meals.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in
or administering USDA programs are prohibited from discriminating based on race, color, national origin,
sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g.,
Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local)
where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may
contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information
may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA
office, or write a letter addressed to USDA and provide in the letter all of the information requested in the
form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter
to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights,
1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
program.intake@usda.gov.
This institution is an equal opportunity provider.
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