Form J-119 - Data Sharing Request/agreement
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8ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Page 1 of 8
J-119 DSA (7-17)
Information Risk Management
3443 North Central, Mail Drop 1426, Phoenix, Arizona 85012
Phone: (602) 771-2676 | Fax: (602) 364-0481
DATA SHARING REQUEST/AGREEMENT
BETWEEN
REQUESTING ENTITY:
DES Division/Administration/Program/Office Name or External Organization Name:
AND
DATA MANAGER: ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division/Administration/Program/Office Name:
DSA Effective Date:
DSA Agreement No.:
Contract Start Date:
Contract No.:
Contract Max End Date:
UID:
(If applicable)
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document
in alternative format or for further information about this policy, contact (602) 771-2670; TTY/TDD Services: 7-1-1. • Free language
assistance for DES services is available upon request. • Disponible en español en línea o en la oficina local.
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