Child Death Case Review Systems Agreement

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Appendix C Holder Confidentiality Agreements Sample Confidentiality Statement for State and Local Users of the Child Death Review Case Reporting System By signing this Agreement, I agree to the following when I access any and all components of the Child Death Review Case Reporting System 1. I will comply with all laws, regulations, policies and procedures as set by the State of 2. I will safeguard the confidentiality of all confidential information to which I have access. I will not carelessly handle confidential information. I will not in any way divulge, copy, release, sell, loan, review, alter or destroy any confidential information except as within the scope of my duties. 3. I will only access confidential information for which I have a need to know and I will use that information only as needed to perform my duties. 4. I will safeguard and will not disclose my user name and password unless authorized by the state administrator of the reporting system. I understand that my user name and password allows me to access confidential information for my team on the Child Death Review Case Reporting System. I understand that the State administrator may revoke my access to the data system if my responsibilities change. * 5. I will promptly report activities by any individual or entity that I suspect may compromise the availability, integrity, security, or privacy of confidential information. 6. I understand that the ownership in any confidential information referred to in this Agreement is defined by State statute. 7. I understand that violating applicable laws and regulations may lead to other legal penalties imposed by the judicial system. Signature: _________________________________ Date: ______________ __ Print Name: ------------------------------- * If your state already has confidentiality statements in place, you might consider replacing this form with your own, hut adding statement four from ahove. 10