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925 Chapter 5:Temporary Assistance for Domestic Violence Survivors (TA-DVS) Program • Section 9: Co-located domestic violence advocates (07/2026) • “I’m here to get your consent.” • Remember, even if the MSC 3010 indicates there can be mutual sharing, community agencies providing DV services generally require their own release to share any information with ODHS staff. Below we have included some examples of how to complete the MSC 3010 that can be helpful. Reminder, these are examples, and each release must be specific to the situation and never standard or “canned” language for domestic violence. ROI for Co- Located DV Advocate Referral • For section titled “Purpose of the disclosure, sharing, and use”
Example language: Referral to advocacy agency for services. Referral information includes name, contact information, and services requested • For section titled “Date of Records”
For hardcopy signatures: Enter the end date of the 90-day certification period OR the time frame requested by the survivor
For verbal signatures: Enter 30 days from the date of the signature OR less time frame requested by the survivor • For section titled “Release TO”
Include the contact information for the domestic violence advocacy agency you are sharing information with. Include the advocate’s name under “contact person” if known ROI for general case staffing with a DV advocate • For section titled “Purpose of the disclosure, sharing, and use”
Example language: TA-DVS eligibility, safety planning, and conversations • For section titled “Date of Records”
Enter the end date of the 90-day certification period OR the time frame requested by the survivor • For section titled “Release TO”
Include the contact information for the domestic violence advocacy agency you are sharing information with. Include the advocate’s name under “contact person” if known ROI for survivor contact information (Potential to use when sharing with other partners such as Child Welfare) • For section titled “Purpose of the disclosure, sharing, and use”
Example language: Home address and phone number • For section titled “Date of Records”
Enter the end date of the 90-day certification period OR the time frame requested by the survivor • For section titled “Release TO”
Include the contact information for the domestic violence advocacy agency you are sharing information with. Include the advocate’s name under “contact person” if known Give the co-located DV advocate information to the survivor to make contact if they choose. Let the survivor know