HomeMy WebLinkAboutC96-012 Colorado Department of Public Health and Environment5TATE O, COLORADO
Roy Romer, Governor OF•c
Patti Shwayder, Acting Executive Director
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Dedicated to protecting and improving the health and environment of the people of Colorado
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Mairi Building laboratory Building r
4300 Cherry Creek Dr. S. 4210 E. 11 th Avenue * 1876
Denver, Colorado 80222-1530 Denver, Colorado 80220-3716 Cojprado Department
Phone (303) 692-2000 (303) 691-4700 lomdo ep2nh
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Memorandum of Understanding
The State has charged the Colorado Department of Public Health and
Environment with detecting and monitoring chronic diseases,
investigating and determining the epidemiology of those conditions,
and establishing programs to detect, prevent and control
environmental and chronic diseases.
The Colorado Registry for Children with Special Needs (CRCSN) of
the Disease Control and Environmental Epidemiology Division of the
Colorado Department of Public Health and Environment is a
statewide, centralized registry of children with birth defects,
developmental disabilities and risks for developmental delay. The
CRCSN conducts epidemiological and health studies including the
assessment of birth defects, developmental disabilities and risks
for developmental delay, and programs for the prevention of
secondary disabilities due to these conditions.
The Eagle County Nursing Service has special knowledge and
authority in public health matters relating to children with
special needs in Eagle County.
The CRCSN and Eagle County Nursing Service agree as follows:
A. 1. CRCSN will provide identifying, locating and diagnostic
information each month concerning children residing in Eagle
County identified by CRCSN.
2. CRCSN will provide a written procedures manual, training
and technical assistance concerning CRCSN for the Eagle County
Nursing -Service.
B. 1. The Eagle County Nursing Service agrees to contact parents
of those children identified by the CRCSN from birth
certificates. In order for the Eagle County Nursing Service
to receive information concerning these children, their
parents have received a letter from the State Registrar of
Vital Statistics, stating that a local public health
representative will contact them and have implied their
consent to be contacted. The Eagle County Nursing Service
will:
Page 1 of 3
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a. explain.the purpose and function of CRCSN,
b. explain the process by which children are identified
by CRCSN,
c. describe what developmental screening, evaluation and
services or other types of services and supports are
available to children and their families,
d. refer the child and family to appropriate
developmental and other types of services and supports.
2. The Eagle County Nursing Service can contact the parents
of children of children identified by CRCSN from sources other
than birth certificates, but is not required to do so as a
condition of this memorandum.
3. Eagle County Nursing Service will return data on each
child to CRCSN on forms provided by the State. These forms
shall be completed and shall be submitted no later than 60
days after the date they were issued by the State. The data
shall include any change in addresses or telephone numbers
known to the Contractor. An example of the form is attached
for reference as Exhibit A.
4. If the parent or legal guardian signs a release to refer
the child to services and gives permission to inform the
child's doctor of the referral to services, then the Eagle
County Nursing Service shall provide the State with a copy of
the release and the name of the child's primary care
physician. An example of the release form is attached for
reference as Exhibit B.
5. a. The Eagle County Nursing Service acknowledges that it
and its employees are subject to the confidentiality
requirements of C.R.S. 25-1-122.
b. Reports and records supplied to the Eagle County
Nursing Service by CRCSN shall be confidential and shall
not be released, shared with any agency or institution,
or made public, except release may be made to the parent
or legal guardian of the child who is the subject of the
report or with written authorization from the parent or
legal guardian.
C. The Eagle County Nursing Service shall obtain a
written release from the parents or legal guardian before
sharing personal identifying information with other
agencies. A example of the release form is attached
hereto for reference and incorporated herein as Exhibit
B.
Page 2 of 3
d. The Eagle County Nursing Service shall notify its
employees that they are subject to the confidentiality
requirements set forth above, and shall provide each
employee with a written explanation of the
confidentiality requirements before the employee is
permitted access to confidential data.
C. 1. Either party- shall have the right to terminate this
agreement by giving the other party thirty days notice by
registered mail, return receipt requested. If notice is so
given, this agreement shall terminate on the expiration of the
thirty days, and the liability of the parties hereunder for
the further performance of the terms of this agreement shall
thereupon cease, but the parties shall not be relieved of the
duty to perform their obligations up to the date of
termination.
2. This agreement is intended as the complete integration of
all understandings between the parties. No prior or
contemporaneous addition, deletion, or other amendment shall
have any force or effect whatsoever, unless embodied in
writing.
The term of this memorandum
1995 to December 31, 1999.
Colorado Registry
Special Needs
Ma
or Children with
&ease Ccintrol and Environmental
pidemiology Division
Colorado Department of Public
Health and Environment
Page 3 of 3
16 �Ln
Dat
I/
Da e
CRCSNIO
Colorado Rrgistry fa Civi Wh special Needs
County(99) 5 11/30/94 (94012345) NOTIFICATION FORM
Child: JONATHON DOE Birth: 08/25/94
123 MAIN ST Phone: 987-1234
ANYTOWN CO 80001
Guardian: MARY DOE
C752 08/25/94 76499 Perinatal, small for gestational age
C412 08/26/94 7470 Circulatory sys: patent ductus arteriosus
C412 08/26/94 7580 Chromosome: Down syn/mongolism/trisomy 22 22 G
C752 09/04/94 7580 Chromosome: Down syn/mongolism/trisomy 22.22.G
C752 09/04/94 7834 Failure to thrive: FTT
HCP 09/13/94 7580 Chromosome: Down syn/mongolism/trisomy 22.22.G
YES NO UNK
1. Is this child already known to your agency? ................................................... 0 0
If YES: Date first known / /19
Did the family initiate contact with your agency because of
aletter from CRCSN?............................................................................ Q, ❑ .
2. Was the family contacted IN PERSON because of this CRCSN referral? .............. 0 0
ff YES: Date contacted / /19
Homevisit...............................................................................
Officevisit................................................................................
Phonevisit................................................................................ 0
ff NO: If no in-person contact with family was made, indicate why.
Didnot attempt to contact.........................................................
Familymoved.....................................................................
Unableto contact.....................................................................
Parentrequested no in-person contact ......................................... El
Already informed of developmental services .................................
Nosuch addressfinadequate address ...........................................
Other (specify El
ff no in-person contact made, SKIP to Comments on next page: -
3. As a result of this CRCSN'referral, did the parent sign -a release to refer
the child to services? 11 El
If YES. Indicate the type of release signed. Attach copy.
ChildFind ................................................................................. El
Other (specify l
ff NO: Check ONE category that BEST describes why a release was not signed.
Parenthad no developmental concerns .........................................
Child already in developmental services ........................................ a
Child terminally ill/died................................................................ El
Other (specify ) 0
STATE Or COLORADO
Roy Romer, Governor
Patti Shwayder, Acting Executive Director
oF'co�
Dedicated to protecting and improving the health and environment of the people of Colorado
e
h r�
Main Building Laboratory Building
It
4300 Chevy Creek Dr. S. 4210 E. 11 th Avenue
1976
Denver, Colorado 80222-1530 Denver, Colorado 80220-3716
Phone (303) 692-2000 (303) 691-4700
Cplp�p t
epar=ea
of %bfic Health
andEnvimnmcat
TO:
Colorado Registry for
Children with Special Needs
Colorado Department of Public
Health and Environment
DCEED-CRC-A3
4300 Cherry Creek Drive South
Denver CO 80222
Name of Parent or Guardian
of
Eagle County Nursing Service
500 Broadway
Eagle, CO 81631
the parent or legal guardian
give my permission for the
Name of Child
Colorado Department of Public Health and Environment and the Eagle County Nursing Service to
release the name, address and medical diagnoses of the child to
Programisl or Agencies
I understand that releasing this information will allow the program(s) to contact me regarding services
that may benefit my child. I understand that participation is voluntary and there is no obligation for
me or the child to cooperate or participate with the program(s). I understand that if I do not sign this
release, this will not affect any health or other services provided to the child by the Colorado
Department of Public Health and Environment or any local agency.
Signature of Parent or Guardian
/ /19
Permission expires one year from date of signature.
I give permission to inform the child's doctor of the referral to the program(s).
Name of Doctor
Street City State Zip Code
Revised October 1994
Telephone
® Printed on Recycled Paper
