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DSA #2018-12-04 <br />INFORMATION SHARING AGREEMENT <br />For <br />CONFIDENTIAL INFORMATION OR LIMITED DATASET(S) <br />Between <br />STATE OF WASHINGTON <br />DEPARTMENT OF HEALTH <br />And <br />KITTITAS COUNTY PUBLIC HEALTH <br />This Agreement documents the conditions under which the Washington State Department of <br />Health shares confidential information or limited Dataset(s ) with other entities. <br />CONTACT INFORMATION FOR ENTITIES RECEIVING AND PROVIDING <br />INFORMATION <br />Page 1 of 16 <br />rev 07/02/2013 <br />INFORMATION RECIPIENT <br />INFORMATION PROVIDER <br />Organization Name <br />Kittitas County Public Health <br />Washington State Department of <br />Health (DOH) <br />Business Contact Name <br />Amy Fuller <br />Christie Spice <br />Title <br />Assessment Coordinator <br />State Registrar and Director <br />Address <br />507 N. Nanum ,St. 102, <br />Ellensburg, WA <br />PO Box 47814 <br />Telephone # <br />509-962-7515 <br />360-236-4307 <br />Email Address <br />amy.fuller@co.kittitas.wa.us <br />Christie.spice@doh.wa.gov <br />IT Security Contact <br />Jim Goeben <br />Sharie McCafferty <br />Title <br />IT Director <br />DOH IT Security Officer <br />Address <br />205 W. 5th Ave., Ellensburg, WA <br />PO Box 49704 <br />Telephone # <br />509-312-0213 <br />360-236-4432 (office) <br />360-236-2290 (emergency) <br />Email Address <br />jim.goeben@co.kittitas.wa.us <br />sharie.rnccafferty4doh.wa.gov <br />Privacy Contact Name <br />Candi Blackford <br />Bruce Dempsey <br />Title <br />Administrative Assistant <br />DOH Public Disclosure Manager <br />Address <br />507 N. Nanum ,St. 102, <br />Ellensburg, WA <br />PO Box 49704 <br />Telephone # <br />509-962-7515 <br />360-236-4221 <br />Email Address <br />candi.blackford@co.kittitas.wa.us <br />bruce.dempsey�r7i doh.wa. ov <br />Page 1 of 16 <br />rev 07/02/2013 <br />