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3. CHISAGO COUNTY FAMILY HOME VISITING [FHV] PROGRAM

   The Chisago County Family Home Visiting [FHV] Program, is a partnership with the Minnesota Department of Health.

5. TENNESSEN WARNING

   Your participation in the Chisago County Family Home Visiting [FHV] Program is strictly voluntary. If you choose to participate, a Family Home Visiting Nurse will ask you for information about yourself and your child(ren) including your age, education level, marital status, public assistance status, health insurance status, race/ethnicity, the language you speak, and you child's birth weight, gestational age, special needs, race/ethnicity, health insurance status, and the language the child speaks. You will periodically be asked for updates to your information. This information will help ensure you receive appropriate services including family home visiting. This information is classified as private data under the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Data related to you and the services you receive will be maintained in a computer database managed by Chisago County.

7. You are not required to furnish any of the information requested. However, providing information will help the nurse to determine if you would benefit from participating in our Program. If you decide not to participate in the Program, your decision will not affect services you may already be receiving from other Chisago County Programs.

   The information applies to your current and future contacts with our Program, through any of the Family Home Visiting Nurses, whether the contact is in person, or by mail, email, fax, or telephone.

9. Sharing Information

   Should you decide to participate, the information you provide to a Family Home Visiting Nurse will only be shared with Chisago County and the Minnesota Department of Health (MDH). If you move to another county while participating in the Program, your data will then be shared with the county to which you move. Chisago County Public Health will not release your private data to anyone else without your consent, unless otherwise authorized by law or court order.

11. I wish to participate in the Chisago County Family Home Visiting [FHV] Program. As a participant, I understand and agree that private data about me and my child(ren) will be shared with by county of residence and the Minnesota Department of Health (MDH). This information will be maintained in a computer data system managed by Chisago County.
13. Chisago County Public Health Nurse*
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15. I agree and consent to providing a digital signature.
17. Client Signature*
18. Relation to Child*
19. Date Signed*
    Date Signed
21. Client Signature
22. Relation to Child
23. Date Signed
    Date Signed
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