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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 Human Services Department (DES Division/Administration/Program/Office Name or External Organization Name) AND DATA MANAGER: ARIZONA DEPARTMENT OF ECONOMIC SECURITY DBME Family Assistance Administration (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.) This request will replace the prior DSA - 08035 for the continued system access to AZTECS for the purpose of using client eligiblity for Food Stamp and TANF programs to determine eligibility for Human Services Department (HSD) - Community Services Division (CSD) programs such as CSBG, LIHEAP utility, and STCS/TANF assistance. Client information regarding DES benefits will be reviewed when a client applies for assistance for programs administered by CSD. Information to be reviewed will include: address; household members, Food Stamp/SNAP, UI and TANF verification. Access to this information will ensure program compliance and will provide the services requested by low-income residents. 1b. INFORMATION TECHNOLOGY AND CONNECTIVITY Connectivity to DES is through the ADOA AZNET – to the CITRIX - DES mainframe / CICS3 AZTECS data via JAVA. The requester enters all information required for successful communication between the requesting entity and the DES IT Staff. Contact Name (1): Margarita Leyvas Phone: (602) 506-4936 Contact Name (2): Tina Tegtmeyer Phone: (602) 506-4844 Contact Address: 234 N. Central Ave. #3000 Phoenix, AZ 85004 Contact (1) E-Mail Address: Contact (2) E-Mail Address: leyvasm@mail.maricopa.gov TegtmeyerT@mail.maricopa.gov Contact Fax No: (602) 506-4749 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 HSD receives funding for services via contract with the AZ DES/DAAS. Those funds include: federal Temporary Assistance for Needy Families (TANF), federal Low-Income Home Energy Assistance Program (LIHEAP), and state Neighbors Helping Neighbors. These program services require verification of income and U.S. citizenship/lawful presence to determine eligiblity. Both can be verified via SNAP, TANF CA, and UI. For non recipients of these 3 programs, AHCCCS can be used to verify U.S. citizenship/lawful presence. 3. WILL OTHER ENTITIES INTERFACE WITH YOUR AGENCY? Yes No If Yes, identify entity and reason(s): 4. WILL IINFORMATION BE DISCLOSED/SHARED WITH ANOTHER ENTITY? Yes No If Yes, identify entity and reason(s) for disclosure: 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.) Information obtained will be printed and placed in confidential client files. These files are maintained in locked cabinets. 7. DESCRIBE SAFEGUARDS IN PLACE TO GUARD AGAINST UNAUTHORIZED ACCESS/DISCLOSURE OF THE INFORMATION The requester is complying with all applicable DES IT and security policies to ensure the protection of confidential data. Client data is maintained in locked cabinets. Access to offices is restricted to employees with specified badge access to our floor. Non-employees and general public must pass through our building security station with guards. All staff complete the DES required security training. Employees are required to maintain all access codes and passwords confidential. PRINT NAME AND TITLE OF AUTHORIZED CONTACT PHONE NO. (602) 506-5911 DATE FAX (602) 506-2613 Bruce Liggett, Human Services Director E-MAIL MAILING ADDRESS/SITE CODE CITY STATE ZIP CODE 234 N. Central Ave. #3000 Phoenix AZ 85004- 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 DSA will be for 5 years beginning the date of approval, unless there is a change to any of the following: entity name, location, ownership, access method or role privileges which would require a new DSA - J-119 be submitted. Print Name PHONE NO. DATE Signature ___________________________________________ ( ) - 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 _______________________________________ SECTION IV (B). HIPAA RECOMMENDATIONS (Completed by the HIPAA DIVISION PRIVACY OFFICER) 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 HSD/Community Services Division Print Signatory Name Denny Barney Title Chairman, MC Board of Supervisors Signature ____________________________________ Date For the Department of Economic Security: Entity Name Print Signatory Name Title 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) (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.