Attachment J-2 Release of Information Privacy Act Waiver.docx
DOCX document 80 KB Posted
- Attached to
- Supportive Housing Services (Up to 180 Days)
- Solicitation number
- 9594CS26Q0075
About this file
This is a Privacy Act Waiver and Release of Information form required as part of the Supportive Housing Services solicitation (9594CS26Q0075) issued by the Court Services and Offender Supervision Agency (CSOSA). The document serves as a template that contractors must utilize to obtain authorized release of participant information necessary for service delivery under the contract. The waiver establishes the legal framework permitting CSOSA and its contractors to access, use, and share confidential information about program participants, typically individuals under court supervision or requiring housing assistance. The form requires participant authorization and includes provisions outlining what information may be released, to whom it may be disclosed, and the purposes for which it may be used in connection with the supportive housing program. This attachment is essential for compliance with federal privacy regulations and enables contractors to coordinate services across multiple agencies and service providers as needed to deliver comprehensive supportive housing assistance for eligible individuals. Contractors responding to this solicitation must be prepared to implement privacy protection procedures and ensure all staff are trained on appropriate handling of sensitive participant data in accordance with Privacy Act requirements and this waiver framework.
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Text version
Attachment J-2 Release of Information-Privacy Act Waiver
Court Services and Offender Supervision Agency for the District of Columbia
Attachment J-2:RELEASE OF INFORMATION PRIVACY ACT WAIVER
I, [Name], hereby authorize and give my prior written consent pursuant to 5 U.S.C. § 552a(b) to the Court Services and Offender Supervision Agency for the District of Columbia, to disclose the information noted below concerning me to the recipient(s) noted below for the purpose noted below.
Information to be disclosed:
Recipient(s):
Purpose of disclosure:
I declare under penalty of perjury that the foregoing is true and correct.
Executed this day of , 202_.
Signature
CSOSA-OGC-0005
Revision: August 2008 Print Form Reset Form image1.png
File details come from the government source that posted it. Updated .