HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA
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1 STATE OF MINNESOTA MINNESOTA DEPARTMENT OF VETERANS AFFAIRS HOMELESS VETERAN REGISTRY NORTHWEST MINNESOTA TENNESSEN WARNING YOUR PRIVACY RIGHTS The State of Minnesota and its partners have committed to end homelessness among Veterans. Minnesota s Homeless Veteran Registry will ensure that every Veteran experiencing homelessness has access to appropriate housing and services. Anyone who served in the U. S. Armed Forces, Reserves, or National Guard can join the Registry, regardless of the type of discharge. If you are a Veteran and choose to join, a team of housing and service professionals will work together to help you access housing and services that meet your needs. Participation is voluntary. You do not have to join, and choosing not to sign the consent will not affect your eligibility for services. Name of Veteran (First, Middle, Last) Birth Date Social Security Number The Minnesota Department of Veterans Affairs (MDVA), as a government agency, is required by law to inform you of your rights when we collect private information from you. This law is the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. This sheet tells you: Why this information is being collected from you and what we do with it. Whether you are legally required to supply this information, or if you may refuse. Any consequences to you of supplying or refusing to supply the requested information. The identity of others authorized by law to receive the information. Why this information is being collected from you: what we will do with the information: We need information about you for these reasons and will use the information as described below: Your name and information about how to contact you, in order to know you from other individuals and to follow up with available services. Your social security number, to gather information about you from other government agencies. Your Veteran status, including type of discharge to determine what benefits you may be eligible for. Your housing status and homelessness history, including history of shelter use and barriers to housing, to determine what services you may have received. Your eligibility for housing programs, which may include whether you qualify for any special kinds of housing based on disabling conditions or any history of drug abuse, alcoholism, or alcohol abuse Your housing and service needs, to connect you to appropriate resources. Names of current and past social service providers, to determine what resources which you have or now are using. Page 1 of 5
2 To assist you to develop effective plans for your medical, social, psychological, educational and other needs. To determine your eligibility for services provided by the Minnesota Department of Veterans Affairs. To determine your eligibility for local, state or federal benefits. To identify the need for a referral to other agencies. To prepare statistical and financial reports and evaluations. For research and studies in which you name will not be identified. To assess and evaluate the quality of programs offered. To conduct satisfaction surveys for you. Whether you may refuse to supply the requested information and the consequences of refusing to supply the information: You have the right to refuse to supply all or any part of the information we request; however, if you do not supply the information requested, among other consequences, we may not be able to: Determine your eligibility for services or benefits. Provide services immediately to you. You will not be denied benefits if you refuse to supply your Social Security Number, in part or in full. However, without it we may not be able to determine your eligibility for certain benefits. Others authorized to receive the information: Private information collected from you will be shared with MDVA staff when necessary for the management of programs and/or services. Except as specified below, information is not given to any person or entity without your written consent or except pursuant to law. Others who may receive the information: County Human Services Departments for Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Pennington, Polk, Red Lake, and Roseau counties County Veterans Services Offices for Beltrami, Clearwater, Hubbard, Kittson, Lake of the Woods, Mahnomen, Marshall, Norman, Pennington, Polk, Red Lake, and Roseau counties Minnesota Assistance Council for Veterans Minnesota Department of Veterans Affairs Northwest Technical College for LinkVet, the Veterans Linkage Line U. S. Department of Veterans Affairs Wilder Research, part of the Amherst H. Wilder Foundation State and Federal Auditors. Appropriate law enforcement personnel who are acting in an investigation, prosecution, criminal or civil proceeding relating to the administration of a program. Courts per a valid court order. Others, pursuant to law. Others you specify: Individually-identifiable health information disclosed pursuant to the authorization may no longer be protected by Federal laws or regulations and may be subject to re-disclosure by the recipient. You understand that: You have the right to refuse to sign this form Your participation in the Registry is voluntary. Services will not be withheld because you chose not to sign. Page 2 of 5
3 You will receive a copy of this form after you sign it. This authorization only covers the types of information described above and does not release medical records, test results, treatment plans, or case notes. You can revoke this authorization at any time by contacting LinkVet toll-free at LinkVet ( ) or by telling staff with an organization participating in the Registry to revoke your authorization. If information has already been released based on this authorization, your request to stop will not work for that information. This authorization takes effect the day that you sign it and expires one year from that date. A copy of this authorization is as valid as the original. For general information on Minnesota Governmental Data Practices: Information Policy Analysis Division Minnesota Department of Administration Administration Building Sherburne Avenue Saint Paul, Minnesota Telephone: or With your signature, you certify that this information has been offered freely, voluntarily, and without coercion and that the information given is accurate and complete to the best of your knowledge. Signature of Veteran Date The Minnesota Department of Veterans Affairs is an Equal Opportunity/Affirmative Action Employer MN RELAY SERVICE: Date submitted to Registry Submitted by (initials) Office use only Sent to MDVA on: Form: HoVeR SLC MDVA Privacy Rights Tennessen (10/14) Page 3 of 5
4 INFORMATION FOR THE REGISTRY To participate in the Registry, the organizations working to help you access housing and services need some additional information. Please provide this information to the best of your ability. Veteran Status 1. Did you serve in the United States Armed Forces, which includes the Army, Navy, Air Force, Marine Corps, and Coast Guard? 2. Did you serve on Active Duty, or in the National Guard or Reserves? 3. If Guard or Reserve: Were you ever called to Active Duty as a member of the National Guard or as a Reservist? 4. Did you enter Active Duty before 9/7/1980? 5. For approximately how many months did you serve? 6. What kind of discharge did you have? 7. Are you receiving VA disability pay? Yes No No Yes, Active Duty Yes, National Guard Yes No Yes No months Don t Know Yes, Reserves Don t Know Don t Know Don t Know Honorable or under honorable conditions Other than honorable, but not dishonorable Dishonorable Don t Know Yes No Don t Know Demographics 8. What is your gender? Female Male Transgender: male to female 9. What is your ethnicity? Non-Hispanic / Non-Latino Hispanic / Latino 10. What is your race? White Black or African- American Asian American Indian or Alaska Native Transgender: female to male Don t Know Don t Know Native Hawaiian or Other Pacific Islander Don t Know Page 4 of 5
5 Contact Information 11. What is the best way to contact you? 12. Do you use any other names or have any aliases? 13. What Minnesota Continuum of Care corresponds to where you live? Central Hennepin County Northeast Northwest Ramsey County Southeast Southwest St. Louis County Suburban Metro Area (SMAC) West Central Don t Know Housing, Income, and Service Needs 14. Where did you stay last night? Unsheltered, outdoors, or a place not meant for habitation Emergency shelter 15. What housing or service programs are you working with now? 16. How many people are in your household, including all adults and children? 17. Do you qualify for any special kinds of housing? 18. What is your typical monthly income from all sources? (If none, enter Ø.) 19. What services or housing options best describe what you need? Long-term homeless Chronic homeless Supportive housing Transitional housing Rapid re-housing Emergency shelter Supportive services Transitional housing Exiting a hospital or institution Currently housed Other: Mental health Sober housing Other: Financial assistance Employment assistance Mental health services Sober housing Other: Thank you for participating in the Registry. If you have any questions about the Registry, please contact LinkVet at When complete, please fax this entire packet (pages 1 5) to LinkVet at The person faxing this form should write their name and phone number below. No fax cover page is required. Transmitted by: Phone number: Page 5 of 5
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