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    Rebecca Wood

    Center for Health Statistics
    Community Assessment
    Texas Dept. of State Health Services
    Mail Code: 1898
    PO Box 149347
    Austin, Texas 78714-9347
    Phone:  (512) 776-6579


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Service Level Agreement

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Between:

Texas Behavioral Risk Factor Surveillance System (BRFSS),
Center for Health Statistics (CHS),
Department of State Health Services(DSHS),
And
(Your Program Name Here)

PURPOSE OF THIS INTERNAL AGREEMENT:

To define the roles of the (Your Program) (herein called “the Program”) and the Texas Behavioral Risk Factor Surveillance System (herein called the “BRFSS”) for conducting surveillance on personal behaviors and health risks for the purposes of promoting health and wellness and preventing disease. Included are the following:

  • Methods for providing resources for surveillance activities
  • Activities that are the responsibility of each party
  • Products
  • Due dates
  • Methods for expanding upon this basic agreement and determining costs

AGREEING PARTIES:

This agreement is between BRFSS and the (Your Program).

AGREEMENT PERIOD:

This agreement is effective on November 1, YYYY. Either party may terminate this agreement by giving 30 days notice to the other party.

SPECIAL PROVISIONS:

(If any, please list.)

BRFSS AGREES TO:

  1. Partner with the Program to include optional/state added questions on the Texas Statewide Behavioral Risk Factor Survey (BRFS) as identified and agreed upon by the Program and BRFSS. (Specific questions, any special instructions used in asking the questions, and the estimated number of respondents are included in Attachment A). Partner with the Program to collect at least 500 BRFS interviews among adults residing in _____ County. Prepare and disseminate results of surveillance findings to the Program in a timely manner. Provide the Program with an electronic copy of the data upon request.
  2. Provide an invoice via E-Mail to the Program for the amount of financial support requested to support the BRFSS.

THE PROGRAM AGREES TO:

Set up a Cat 2000 funding source for the amount invoiced and provide BRFSS with the following information:

Dept. ID:
Project/Grant:
Program Code:
Fund:
Class:
Appropriation #:
CFDA Number:
Expiration Date (mm/dd/yyyy) for funding source:

The resources provided will be used to support continued statewide data collection of behavioral and other health risk factors. The BRFSS Coordinator anticipates that a total of 500 - 600 interviews with Texas adults will be completed each month.

IT IS MUTUALLY AGREED THAT:

  1. Data collected by BRFSS will be made available to the public in a manner that is consistent with the protection of respondent confidentiality. The confidentiality of personal data collected by BRFSS will be protected in accordance with all applicable state, federal, and institutional laws, regulations, assurances, and policies following the highest ethical standards for survey research.
  2. No changes in survey questions will be made without approval of both parties and CDC. If questions are incorporated into the core or into the added modules, they may not be changed.

Must be Approved by:

The Manager of DSHS/Public Health Program and
the Director of Center for Health Statistics

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Last updated May 30, 2013