Template for Interagency Memorandum of Understanding

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       INTERAGENCY AGREEMENT/MEMORANDUM OF UNDERSTANDING
                    Template and Sample Components


Title: IA or MOU between ______________________and _____________________.

Purpose and Intent: The purpose of the agreement is to outline policies and
procedures related to the roles and responsibilities of agencies serving children under
three who are involved in a substantiated case of abuse and neglect.-
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Parties: List the parties that are included in the agreement and have authority over
implementation of the components.
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Philosophy: A statement of guiding principles reflecting the common beliefs held by
both/all agencies.
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Target Population: Infants/toddlers birth to age three years of age involved in a
substantiated case of abuse and neglect that may need early intervention services.
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Definition of Terms: The parties may want to include terminology used by both
agencies, such as “substantiated”, service coordinator, infants/toddlers with special
needs.
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Goals and Objectives: the agreement reflects the collaborative purpose of working
together and the goals that are expected to be achieved.
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Agreement Content: In this section the parties describe the resources and procedures
they agree to undertake to provide services to the target populations. Components may
include:
     Screening (who, when, tools utilized, sharing results, follow along, criteria for
       referral to early intervention)
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    Referral procedures (referral form, confirmation of receipt of referral,)
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     Sharing information [common release of information form, Information to be
      shared (e.g. medical or developmental reports, IFSP documents), status of
      parent’s educational rights]
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    Consent for evaluation, assessment and provision of early intervention services
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Staff Responsibilities: List various staff members’ responsibilities for implementing
the agreement, such as individual agency contacts, central points for referrals, service
coordination procedures and service provision duties.
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Training: Include annual training activities, training content and who will be required to
attend.
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Interagency Meetings: This section includes statement about purpose, frequency of
interagency meetings and who will attend from participating agencies.
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Data Collection and Analysis: The parties discuss how they plan to collect data,
either by each agency alone or in collaboration according to state and national
accountability standards, how to evaluate the effectiveness of their interagency efforts.
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Dispute Resolution: General dispute-resolution procedures are outlined in this
section. It is suggested that each agency have their legal department review and
approve the procedures.
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Terms of Agreement: The period of time during which the agreement will be in effect
will be determined. The agreement will be reviewed annually to determine how it will be
revised and how it will be terminated.
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Authority: A statement above the signatures that specifies the authority of the
directors for agreeing to comply with the provisions contained in the agreement.
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Signatures of Agency Directors: Spaces are provided, together with datelines, for the
signatures of agency representatives authorized to implement the agreement for their
respective agencies.
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