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55 Section N: Duties Rela4;ng do R:g~,c ors„b~eocs <br />INSTRUCTIONS TO ENTITIES FOR USING THIS FORM <br />These instructions correspond to the lettered sections on the reverse side of this form. Use plain <br />language when tailoring this form to accommodate your entity's specific needs. <br />A. Enter the complete name and address of the entity that maintains the information. Include <br />any relevant program names, staff names, titles and phone numbers. <br />B. Identify, as specifically as possible, the reports, record names or types of information or <br />records that will be released. <br />C. Identify the entity or entities to which the information will be released. Include the name <br />and address of the entity. Include relevant staff names and titles. Be specific. <br />D. Describe specifically and completely the purpose(s) for seeking the client's informed <br />consent and the new use(s) to which the information will be put. <br />E. Describe specifically and completely the consequences to the data subject of releasing the <br />• information. This means all of the consequences known to the entity at the time the consent <br />is signed. <br />F. Describe specifically and completely the consequences to the data subject of not releasing <br />the information. This means all of the consequences known to the entity at the time the <br />consent is signed. <br />G. Instruct the client to sign the consent and enter the date on which the consent is signed. <br />H. As a general rule, a parent or guardian's signature should be obtained when the client is <br />under the age of 18 or has a legally appointed guardian; however, specific requirements for <br />obtaining consent to release data in these circumstances vary. Instructions for completing <br />this portion of the form within your particular entity should be developed in <br />consultation with your legal advisor. <br />~uiy, iuuu Model Policy: Access to Government Data & Rights of Subjects Data <br />