Data Privacy/Tennessen Warning

All information you provide about you and your household is considered private data as defined by the Minnesota Government Data Practices Act and cannot be shared outside of CAC. This act protects your rights to:

• Control information about yourself and your family.
• Allows you to grant CAC permission to share information about you and your family with other service providers. A separate release of information will be provided to you in order to grant us permission.

This information will be used by the Community Action Center to help determine possible eligibility for services that may assist you and your family. Program funders including the Minnesota Department of Human Services, Department of Housing and Urban Development, Minnesota Housing Finance Agency, MN Department of Employment and Economic Development, Three Rivers Community Action (if accessing LHPA funding), CAC staff, and fiscal auditors may review client program files. Information that identifies you or any member of your household will never be revealed without your written permission. You may not be required to provide information, but without it, we may not be able to find the appropriate help for you. Giving us incorrect information or not providing complete information may delay or eliminate some services for which you would be eligible.

The Community Action Center will keep your information for seven (7) years from the last date of service or until program audits are completed.

You may make a request to review your records during agency hours by contacting the program manager. If you have questions about the information in your record, you may ask to have it explained to you. You may also ask for copies of information in your file by providing a written request. CAC can also provide copies to a third party, given written permission is given for others to see your private data.

I have read and understand my data privacy rights and responsibilities.

Grievance Policy

The Community Action Center (CAC) believes that effective communication is essential to the agency’s continued success. In addition, open lines of communication are important to the creation of productive work relationships between staff and clients and to the elimination of counterproductive conflict.

The CAC realizes, however, that there may be occasions when the nature of communication is such that people cannot work together effectively. When this happens, please present problems or concerns at the time they arise, whenever possible.

Again, as part of the agency’s commitment to effective communication, staff encourage you to share any problems or concerns, with the goal of having them settled within 30 days.

The following steps explain the procedure for doing this. Start with Step 1. If there is still no resolution to the issue, go to the next step:

1. Discuss the issue with the CAC staff person or volunteer with whom you are working. If unsatisfactorily resolved, go to Step 2.
2. Discuss the issue with the supervisor of the CAC staff person or volunteer with whom you are working. If unresolved, go to Step 3.
3. Discuss the issue with the Community Resource Director. If the issue is unresolved at this time, the Community Resource Director will help you in bringing your concern to the Senior Program Director.
4. Discuss the issue with the Senior Program Director. If the issue is unresolved at this time, the Senior Program Director will help you in bringing your concerns to the Executive Director.
5. Discuss the issue with the Executive Director. If unresolved, the Executive Director will help you bring your concern to the Board of Directors.

CAC staff will make every effort to address your concern promptly. Depending on the nature of the matter, at any point there may be a request to have a written summary of the matter under concern.

Because of potential staff changes, this policy does not name the specific people in staff positions. Call the CAC receptionist to ask who the contact person is for the position in question. You do not need to explain why you want the information.

USDA Non‐Discrimination Statement

This institution is an equal opportunity provider.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877‐8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD‐3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632‐9992. Submit your completed form or letter to USDA by:

(1). mail: U.S. Department of Agriculture, Assistant Secretary for Civil Rights
1400 Independence Avenue, SW Washington, D.C. 20250‐9410;
(2) fax: (202) 690‐7442; or
(3) email: vog.adsu@ekatni.margorp.

The Emergency Food Assistance Program (TEFAP) Annual Eligibility Form

To be eligible for food assistance through TEFAP:

• • Self-report the information in the table below
  • Self-declare that:
    • You are in Minnesota.
    • Your household income is at or below the income listed for the number of people in your household.

The following is NOT required:

• • No Identification, No Proof of Address, No Proof of Income, No Proof of Household Size.
  • No Social Security Number, No Proof of Citizenship/Immigration Status
  • No information other than what is on this form can be required from you to access food at this site.

Annual Income Eligibility: (300% of Federal Poverty Guidelines)

*Add $17,040 for each additional member

I self-declare that:

• I am in Minnesota.
• My household income is at or below the above guidelines.
• The information I provided is correct to the best of my knowledge and ability.
• I have been shown and have read the USDA Nondiscrimination Statement.
• I have been shown and have read the MN Data Privacy Notice.