DES DATA-SHARING AGREEMENT AMEND 4.PDF

J-119 DSA (11/2013) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Information Security Administration,
1720 W. Madison St., Site 820Z
Phoenix, AZ 85007
Phone: (602) 771-2670 · Fax: (602) 364-0481
DATA-SHARING REQUEST/AGREEMENT
BETWEEN
REQUESTING ENTITY:
Maricopa County
(DES Division/Administration/Program/Office Name or External Organization Name)
AND
DATA MANAGER: ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DERS/Employment Administration (EA)
(Division/Administration/Program/Office Name)
Effective Date: Agreement No.:
Equal Opportunity Employer/Program
This document available in alternative formats by contacting: (602) 771-2670.

J-119 DSA (11/2013) - PAGE 2 Agreement No.:
SECTION I. REQUEST (Completed by Requesting Entity)
Use attachment if necessary
1a. PURPOSE OF THIS REQUEST (What information is being requested and why? How will it be used? Give details/specifics.)
Arizona Job Connection (AJC) access is requested per the following table:
Role Program Access Program Access Program Access
WIA Regional Director ES R WIA W TAA R
WIA Supervisor ES R WIA W TAA R
WIA Case Tracker ES R WIA W TAA R
R = Read Only W = Read, Write
Per the United States Department Of Labor (DOL) the Workforce Investment Act (WIA) program, Employment
Service program, and Trade Adustment Assistance (TAA) program are all under the umbrella of “Common
Measures/Common Reporting”. This means each program must be aware of what the other programs are doing
with clients shared between the programs. Therefore the WIA program staff will need access to shared client
data. This is why it is necessary to have Read and Write access granted to the Local Workforce Investment
Administration (LWIA) for all programs contained within the AJC application, as shown in the above table.
1b. INFORMATION TECHNOLOGY AND CONNECTIVITY
The requestor describes the information technology (IT) environment that will connect to DES. (be explicit – consult your
IT personnel for assistance.
Connectivity to the Arizona Job Connection will be through the Internet via the LWIA Network.
The requestor enters all information required for successful communication between the requesting entity and the DES IT
Staff.
Contact Name (1): Tina Luke Phone: (602) 372-9378
Contact Name (2): Aaron Roth Phone: (602) 372-0722
Contact Address: 735 N. Gilbert Rd, Suite #134 Gilbert AZ 85234
Contact (1) E-Mail Address: LUKET@mail.maricopa.gov Contact (2) E-Mail Address: ROTHA@mail.maricopa.gov
Contact Fax No: (602) 372-3794

J-119 DSA (11/2013) - PAGE 3 Agreement No.:
SECTION I. (cont.) REQUEST (Completed by Requesting Entity)
Use attachment if necessary
2. CITE LAW, REGULATION, DIRECTIVE OR OTHER BASIS FOR THIS REQUEST
Wagner-Peyser Act; Workforce Investment Act (WIA) of 1998, PL 105-220.
3. WILL OTHER ENTITIES INTERFACE WITH YOUR AGENCY?
Yes No If Yes, identify entity and reason(s):
If Yes at your locations, complete Attachment A.
If Yes at other locations, each entity must complete its own separate data sharing agreement.
4. WILL IINFORMATION BE DISCLOSED/SHARED WITH ANOTHER ENTITY?
Yes No If Yes, identify entity and reason(s) for disclosure:
If Yes at your locations, complete Attachment A.
If Yes at other locations, each entity must complete its own separate data sharing agreement.
5. WILL DES DATA BE REPACKAGED/INCLUDED IN OTHER DATA BASES, FILES, TAPES, ETC.
Yes No If Yes, identify entity and reason(s):
6. DESIRED OUTPUT (Printout, tape, terminal access/display, etc.)
Output will be obtained through internal printable reports contained within the application and accessed on-line via the
Internet.
7. DESCRIBE SAFEGUARDS IN PLACE TO GUARD AGAINST UNAUTHORIZED ACCESS/DISCLOSURE OF THE INFORMATION
The requester is complying with, or will comply with, all applicable Arizona Department of Economic Security (ADES) IT and
security policies to ensure the protection of ADES confidential data
PRINT NAME AND TITLE OF AUTHORIZED CONTACT PHONE NO. (602) 372-9738 DATE
Tina Luke FAX (602) 372-9794 1/21/2015
Regional Manager E-MAIL LUKET@mail.maricopa.gov
MAILING ADDRESS/SITE CODE CITY STATE ZIP CODE
735 N. Gilbert Road Gilbert AZ 85234-
#134

J-119 DSA (11/2013) - PAGE 4 Agreement No.:
SECTION II. STIPULATIONS REGARDING THE USE OF INFORMATION
STIPULATIONS APPLICABLE TO THE REQUESTING ENTITY:
1. Disclosure of the data provided to the Requesting Entity is not permitted unless specifically authorized.
2. Repackaging or redistribution of data or screens, or creation of separate files will not be permitted unless specifically authorized.
3. The data shall be used only to assist in valid administrative needs as stated in Section I, item 1 of this Agreement.
4. All data shall be stored in a physically secure facility.
5. All data in electronic format shall be stored or processed so that unauthorized persons cannot retrieve the information by means of a
computer, remote access, or other means.
6. Only authorized staff will be given access needed to accomplish the purpose(s) specified in Section I, item 1 of this Agreement.
7. All staff shall attend an authorized data security awareness training class, where they will be instructed on confidentiality, privacy
laws and penalties imposed when compliance is breached. All staff with access to DES systems and/or applications must complete
an annual recertification security awareness training class as scheduled by DES.
8. A Request for Terminal Access and Other Activity (J-125) shall be used to request specific access for each authorized staff
member and must be signed by the staff supervisor or designee.
9. All authorized staff is required to sign a User Affirmation Statement (J-129), as a condition for using requested data. This
affirmation statement must be resigned at three (3) year intervals as scheduled by DES.
10. Any personnel changes requiring change or removal of access as described in Section I, item 1 of this Agreement, shall be reported
promptly to the respective data security analyst.
11. Federal and state audit and data security personnel may have access to offices and records of the requesting entity to monitor or
verify compliance with this agreement.
12. This Data-Sharing Agreement will remain in effect for 10 years from the effective date unless otherwise stipulated in Section III
or overridden by the Contract, a Memorandum Of Understanding or an InterAgency Agreement. If length is overridden by another
document, please reference the document in Section III.
STIPULATIONS APPLICABLE TO PROVIDER:
1. DES will use the Requesting Entity employee identifying information solely for the purpose of establishing on-line access.
2. Only authorized DES employees will have access to requesting agency employee data.
3. In accordance with applicable federal, state, and/or local privacy regulations, DES will protect all information collected from the
Requesting Entity.
STIPULATIONS APPLICABLE TO HIPAA – HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT:
1. All staff shall attend an authorized HIPAA awareness training class, where they will be instructed on confidentiality, privacy,
information safeguards and penalties imposed when compliance is breached.
2. If applicable, there is a “Business Associate Contract” [45 CFR 164.502(e), 154.504(e). 164.532(d) & (e)] on file and will be
attached to this data sharing agreement as an addendum.

J-119 DSA (11/2013) - PAGE 5 Agreement No.:
SECTION III. ADDITIONAL INFORMATION
1. Access is authorized and provided as requested in Section I, Item 1a.
2. Section I, Item 2 notation: On July 1, 2015, the Workforce Investment Act will be superseded by the Workforce
Innovation and Opportunity Act, signed by President Barack Obama on July 22, 2014. The terms of this agreement
will not be otherwise affected when this occurs.
Print Name Steve Chucri, Chairman PHONE NO. DATE
Signature ___________________________________________ (602) 506-7431
SECTION IV (A). RECOMMENDATIONS (Completed by the data managing program)
Recommend APPROVAL
Request is not recommended for approval.
Print Name SITE CODE PHONE NO. DATE
( ) -
Signature _______________________________________

J-119 DSA (11/2013) - PAGE 6 Agreement No.:
SECTION V. APPROVAL (Completed by the requesting entity and the data managing program)
I attest to the correctness of the information provided in Section I and agree to the stipulations and costs listed in Section II and III. I
agree to comply with all provisions of the DES Data Security Policy. Should any violations of the DES Data Security Policy occur, this
Agreement may be terminated. I further understand that DES will periodically review the terms of the Agreement to ensure it conforms
with DES Policies and Procedures. In the event changes in either federal or state law or regulations occur that conflict with the terms of
the Agreement or render the terms of the Agreement void, impracticable, or otherwise impossible, this Agreement will terminate
immediately. A new Agreement or an amendment to the existing Agreement will be initiated to provide for any changes, which cannot
be accommodated within the provisions of the existing Agreement. The Requesting Entity shall hold harmless and indemnify the State
of Arizona and its Department of Economic Security for any liability resulting from acts or ommissions attributable to the Requesting
Entity.
IN WITNESS HERETO, the PARTIES have executed this Agreement by signature of their duly authorized officials:
For the Requesting Entity:
Entity Name Maricopa County
Print Signatory Steve Chucri, Chairman
Name
Title Maricopa County Board of Supervisors
Signature ____________________________________
Date
For the Department of Economic Security:
Entity Name Division of Employment and Rehabilitation Services/Employment Administation
Print Signatory Joel Millman
Name
Title Program Administrator
Signature ____________________________________
Date
SECTION VI. APPROVAL (Completed by the Information Security Administration)
This signed Agreement meets all requirements necessary to permit the controlled sharing of the DES data while simultaneously
providing for the protection of the data. I certify that:
THIS AGREEMENT CONFORMS to DES Information Security Policy.
THIS AGREEMENT DOES NOT CONFORM to the DES Information Security Policy. Implementation of this
Agreement cannot proceed until the following action is taken:
Carl Carpenter
DES Chief Information Security Officer
(Signature) (Print Name and Title) (Date)

Equal Opportunity Employer/Program
• Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA),
Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information
Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department
must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For
example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a
wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable
action that allows you to take part in and understand a program or activity, including making reasonable changes to an
activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability,
please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for
further information about this policy, contact Paul Chalker, DTS Information Risk Management, 602-771-2675; TTY/TDD
Services: 7-1-1. • Free language assistance for DES services is available upon request.