Att 12_Agreement for Cross-Jurisdictional

Agreement for Cross-Jurisdictional Data Collection by the Medical Monitoring Project

Name of State, City, or Territorial Health Department: _____________________________________________

The intent of this document is to establish agreements between jurisdictions regarding the recruitment of persons sampled for the Medical Monitoring Project (MMP) that no longer reside in the jurisdiction in which they were sampled. It is not intended to alter or limit the exchange of routine HIV case surveillance information. As such, MMP staff may contact any other surveillance program to conduct routine surveillance activities such as record searches or provision of updated case surveillance information regardless of the selection made below.

As the Overall Responsible Party (ORP) for my jurisdiction, I ask that the following guidance be observed when recruiting persons sampled from case surveillance records in another jurisdiction for MMP who currently reside in my jurisdiction:

Option 0 – My jurisdiction grants approval for this activity without notification. The jurisdiction of sampling is permitted to recruit persons residing in my jurisdiction at-will without notifying our public health department.

Option 1 – My jurisdiction grants approval for this activity with prompt notification following recruitment. The jurisdiction of sampling will notify my jurisdiction’s designee of encounters with sampled persons residing in my jurisdiction within 3 business days. I understand that, in some uncommon instances, the jurisdiction will not be legally allowed to disclose the name of the person, and notification of the encounter without name disclosure is sufficient in these instances.

Option 2 – My jurisdiction grants approval for this activity with notification prior to recruitment. The jurisdiction of sampling will notify my jurisdiction’s designee of plans to contact and recruit someone in my jurisdiction. My jurisdiction’s designee may deny recruitment of any such persons within 5 business days of initial notification. I recognize that in some cases the jurisdiction of sampling may unintentionally contact a person residing in my jurisdiction, e.g. by dialing a telephone number. In such cases, the sampled person may immediately be given the opportunity to interview out of respect for the person’s time. However, my jurisdiction will be notified of the encounter with this sampled person by name within 3 business days. If I select this option, jurisdictions not legally allowed to disclose the name of the contacted person to my jurisdiction will not be allowed to conduct this activity in my jurisdiction.

Option 3 – My jurisdiction refuses all MMP recruitment on sampled persons that currently reside in my jurisdiction.

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Cross-jurisdictional medical record abstraction will only be conducted with a signed medical record release from the patient using methods that comply with all National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention security and confidentiality guidelines such as mail or secure fax. None of the options above imply permission to physically enter my jurisdiction for the purpose of cross-jurisdictional data collection without additional permission. Jurisdictions of sampling are required to assist my jurisdiction by providing any information to enhance case surveillance that they may legally provide. The point of contact for MMP cross-jurisdictional activities, including facilitation of case surveillance reporting to my jurisdiction as well as linkage and re-engagement services, is:

_______________________________ ____________________ ___________________ _______________

Name of point of contact/designee Title Telephone number Email address

This agreement will be honored by the Medical Monitoring Project until amended by my jurisdiction in writing.

_______________________________ ______________________________ ___________________________

Signature of ORP Signature of Surveillance Coordinator MMP Principal Investigator (if applicable)

_______________________________ ______________________________ ___________________________

Name of ORP Name of Surveillance Coordinator Name & Title of MMP PI

_______________________________ ______________________________ ___________________________

Date Date Date

Please return this completed agreement to the MMP team c/o Sandra Stockwell at sstockwell@cdc.gov.