AZDHS MEMORANDUM OF AGREEMENT AMENDMENT.PDF

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 1 of 8 
Revised 04/08/2024 
     ARIZONA HEAD START ASSOCIATION 
Effective upon signature by both parties it is mutually agreed that the Memorandum of Agreement is amended as follows: 
1.
Pursuant to the Terms and Conditions, Provision Ten (10) Amendment or Modifications, the Agreement is hereby
revised with the following:
1.1 The MOU number has been updated to HU350053.
1.2 The Scope of Work has been revised and replaced.
ALL CHANGES ARE REFLECTED IN RED 
ALL OTHER PROVISIONS SHALL REMAIN IN THEIR ENTIRETY 
Contractor hereby acknowledges receipt and acceptance of above amendment and that a signed copy must be filed with 
the Procurement Office before the effective date 
The above referenced Amendment is hereby executed this _____ day of __________ 20______ at Phoenix, Arizona 
________________________________________ 
Procurement Officer Signature

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 2 of 8 
Revised 04/08/2024 
SCOPE OF WORK 
1.
Background
1.1. 
Head Start: 
1.1.1. 
This Agreement is made under the Authority of the Economic Act, approved June 30,1932, as 
amended (31 U.S.C. 1535). 
1.2. 
Women, Infants and Children Program (WIC) 
1.2.1. 
The WIC Program is authorized by Section seventeen (17) of the Child Nutrition Act of 1966 (42 
U.S.C 1786), as amended. The WIC Program is one of several programs administrated by the 
Food and Nutrition Service that serves low- income women and children, and 
1.2.2. 
This agreement is entered into pursuant to the authority of 7 CFR 246.26 (d) of the Federal 
Regulations, USDA Food and Nutrition Service Instruction 800-1, and USDA WIC Final Policy 
Memorandum #2001-01. 
2.
Objective
2.1. 
The purpose of this Memorandum of Understanding (MOU) between the Arizona Head Start Association 
Program Members and Women, Infants and Children Division (WIC) is to facilitate coordination of services 
and ensure confidentiality of data to improve health outcomes and access to WIC services among at-risk 
children at local WIC and Head Start offices throughout Arizona. It also serves to streamline administrative 
procedures for staff, participants, and applicants of both the WIC and Head Start programs. The WIC and 
Head Start programs at the state and local level will partner to meet this goal. These agencies will work 
together to promote and support State, regional and local efforts to improve program coordination and 
services delivery for low-income children and their families who are eligible to participate in the Head Start 
Program and the Special Supplemental Food Program for Women, Infants, and Children (WIC); and 
2.2. 
The parties to this Agreement each acknowledge that the other possesses and will continue to possess 
confidential information that has been developed or received by it. The use or disclosure of information 
concerning services, applicants or recipients obtained in connection with performance of this Agreement 
shall be restricted to purposes directly connected with the administration of the programs implemented by 
this Agreement. The Head Start and Early Head Start programs may use WIC Program information only 
for the purposes of conducting outreach and/or establishing the eligibility of WIC applicants or participants 
for Head Start or Early Head Start programs. 
3.
Tasks
The Contractor shall:
3.1. 
Provide WIC with Head Start-enrolled child information to include: 
3.1.1. 
First Name, 
3.1.2. 
Last Name,

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 3 of 8 
Revised 04/08/2024 
3.1.3. 
Middle initial (when available), 
3.1.4. 
Date of Birth, 
3.1.5. 
Address (In the case a. through d. are not sufficient identifiers), 
3.1.5.1. 
Child’s First and Last Name; 
3.1.5.2. 
Child’s Date of Birth; 
3.1.5.3. 
Parent’s First and Last Name; 
3.1.5.4. 
Phone number; 
3.1.5.5. 
Address, and; 
3.1.5.6. 
Email. 
3.1.6. 
Parent Contact Information, for future outreach, and 
3.1.7. 
Parent/Guardian Signature, to consent to be contacted for future outreach. 
3.2. 
Share data in a confidential, secure manner. If electronic protected health information (ePHI) is 
shared, it must be encrypted prior to transmission; 
3.3. 
Provide WIC at least one (1) to two (2) weeks’ notice to respond following receipt of child identification 
information depending on the length of the list; 
3.4. 
Work cooperatively to resolve questions and concerns about the identification of children, incomplete 
or inaccurate information; 
3.5. 
Communicate between WIC and Head Start grantees to best support information sharing meeting 
confidentiality requirements of the population served including the establishment of local liaisons and 
methodologies to fulfill MOU requirements; 
3.6. 
Collaborate based on guidelines outlined in Attachment A; 
3.7. 
Restrict the use or disclosure of information received pursuant to this MOU to any third (3rd) party 
unless there is a separate Release of Information obtained from the client / parent / guardian;  
3.8. 
At the State level, provide a copy of this Agreement to local Head Start grantees via the Arizona Head 
Start Association Website, the Arizona Head Start Collaboration Office, and hard copy available upon 
request; and  
3.9. Share data related to WIC enrolled children’s names, date of birth, contact information, 
anthropometric values, hemoglobin values, and dates of measurement.

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 4 of 8 
Revised 04/08/2024 
4.
State Provided Items
ADHS will:
4.1. 
Inform clients that personal information about WIC recipients may be shared with Head Start;
4.2. 
Share data related to Head Start enrolled children's name, date of birth, contact information,
anthropometric values, hemoglobin values, and dates of measurements; 
4.3. 
Provide Head Start with WIC-enrolled child information to include: 
4.3.1. 
First Name, 
4.3.2. 
Last Name, 
4.3.3. 
Middle Initial (when available), 
4.3.4. 
Date of Birth, 
4.3.5. 
Address (In the case a. through d. are not sufficient identifiers), 
4.3.6. 
Parent Contact Information, for future outreach, and 
4.3.7. 
Parent/Guardian Signature, to consent to be contacted for future outreach. 
4.4. 
Share data in a confidential, secure manner. If electronic protected health information (ePHI) is 
shared, it must be encrypted prior to transmission; 
4.5. 
Restrict the use or disclosure of information received pursuant to this MOU to any third party unless 
there is a separate Release of Information obtained from the client/ Authorized Person; 
4.6. 
Communication will be designed locally between WIC and Head Start grantees to best support 
information sharing, meeting confidentiality requirements of the population served, including the 
establishment of local liaisons and methodologies to fulfill MOU requirements; 
4.7. 
Collaborate based on guidelines outlined in Exhibit A; and 
4.8. 
At the State level, provide a copy of this Agreement to local agencies. 
5.
Notices, Correspondence and Reports
5.1. 
Notices, correspondence and reports from the Contractor to ADHS shall be sent to: 
Arizona Department of Health Services 
150 N 18th Avenue, Suite 320 
Phoenix, AZ 85007 
Phone: (602) 5421886 
Email: tasha.williams@azdhs.gov

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 5 of 8 
Revised 04/08/2024 
6.
SIGNATURES/APPROVALS
FOR: CATHOLIC CHARITIES
FOR ARIZONA DEPARTMENT OF HEALTH 
SERVICES: 
________________________________
_________________________________ 
 Procurement Officer
Phone: __________________________
Date: ____________________________ 
Email: ___________________________
Date: ____________________________
FOR: CHILD CRISIS AZ 
_____________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________ 
FOR: CHILD-PARENT CENTERS 
 ________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 6 of 8 
Revised 04/08/2024 
FOR: CITY OF PHOENIX 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________ 
FOR: MARICOPA COUNTY 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________ 
FOR: NORTHERN AZ COUNCIL OF GOVERNMENTS 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 7 of 8 
Revised 04/08/2024 
FOR: PINAL GILA COMMUNITY CHILD SERVICES 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________ 
FOR: SOUTHWEST HUMAN DEVELOPMENT 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________ 
FOR: WESTERN AZ COUNCIL OF GOVERNMENTS 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________

MEMORANDUM OF AGREEMENT 
AMENDMENT 
ARIZONA DEPARTMENT OF 
HEALTH SERVICES 
OFFICE OF PROCUREMENT 
150 N 18th Ave., Ste. #530 
Phoenix, Arizona 85007 
MOU NO.: HU350053 
AMENDMENT NO.: 1 
PROCUREMENT OFFICER: 
Kailee Gray 
Page 8 of 8 
Revised 04/08/2024 
FOR: URBAN STRATEGIES 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________ 
FOR: CHICANOS POR LA CAUSA 
________________________________ 
Phone: __________________________ 
Email: ___________________________ 
Date: ____________________________