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I'Veal th <br />DOH 422-113 August 2017 <br />Center for Health Statistics <br />P.O. Box 9709 <br />Olympia, WA 98504-9709 <br />360-236-4310 <br />Business Contact Name <br />Tristen Lamb <br />Title <br />Interim Public Health Administrator <br />Address <br />507 Nanum St. Suite 107, Ellensburg, WA 98926 <br />Telephone # <br />509-962-7003 <br />Email Address <br />amy.fuller@co.kittitas.wa.us <br />Data User Contact Name <br />Amy Fuller <br />Title <br />Assessment Coordinator <br />Address <br />507 Nanum St. Suite 107, Ellensburg, WA 98926 <br />Telephone # <br />509-962-7002 <br />Email Address <br />am .fuller co.kittitas.wa.us <br />IT Security Contact Name <br />Jim Goeben <br />Title <br />IT Director <br />Address <br />205 W 5th Ave, Ellensburg, WA 98926 <br />Telephone # <br />509-312-0213 <br />Email Address <br />jim.goeben@co.kittitas.wa.us <br />Privacy Contact Name <br />Candi Blackford <br />Title <br />Administrative Supervisor <br />Address <br />507 Nanum St. Suite 107, Ellensburg, WA 98926 <br />Telephone # <br />509-962-7515 <br />Email Address <br />candi.blackford@co.kittitas .wa.us <br />Ota user Conlaet: the person who will receive the data <br />Business Contact: a person with authority to sign the agreement for entire agency or organization. The Business Contact will be responsible for <br />maintaining a signed Appendix A for all individuals who have access to the data file(s). Appendix A forms are available upon request. <br />1T 5ecur4y Contact: a person with responsibility for ensuring data are stored and transferred in accordance with federal and state laws and <br />regulations. <br />Privacy Contact: a person with responsibility for privacy/public disclosure requests; ensuring compliance with HIPAA; ensuring data are <br />maintained in accordance with federal law. <br />DOH 422-113 August 2017 <br />