NAME OF SCHOOL OR SCHOOLS

							                             Sample Data Agreement
DATE

SCHOOL / AGENCY / ORGANIZATION / HOSPITAL
ADDRESS

COALITION
ADDRESS

To Whom It May Concern:

This letter is authorization for the COALITION to use the SCHOOL / AGENCY /
ORGANIZATION / HOSPITAL DATA for YEAR-YEAR.

We understand that:

      These data will be used for a COUNTY needs assessment and strategic plan.
      De-identified data will be provided to the coalition implementing Communities
       That Care (CTC) and Indiana Prevention Resource Center staff.
      Data will be aggregated to avoid identification of individuals.
      Secondary analysis of these data may be conducted for research purposes with
       prior approval from an institutional review board.
      A copy of the needs assessment and strategic plan may be provided to each
       SCHOOL / AGENCY / ORGANIZATION / HOSPITAL’s designated
       representative upon request.
      The report will be distributed throughout the community and state, which may
       include distribution by media outlets and inclusion in other public documents.
      The report may be used to procure grant funds.
      SCHOOL / AGENCY / ORGANIZATION / HOSPITAL representatives are
       welcome to be members of the coalition.

Sincerely,



_____________________________________________
SCHOOL / AGENCY / ORGANIZATION / HOSPITAL
REPRESENTATIVE




_____________________________________________
CTC COMMUNITY COORDINATOR