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Page 7 of 8 <br /> <br />If you have a disability and need this document in another format, please call 1 -800-525-0127 (711-TTY relay). <br />DOH 348-576 November 2017 <br />ATTACHMENT B <br /> <br />IIS Confidentiality Agreement <br /> <br />I understand that my employer, _________________, (insert name of Employer) has entered into an <br />Information Sharing Agreement with the Washington Department of Health to view and/or exchange data in the <br />Washington State Immunization Information System (“IIS”). My employer has made a copy of the Agreement <br />available to me. <br /> <br />I understand that I am responsible for maintaining the confidentiality of any IIS Immunization Data that I have <br />access to during the course of my employment. IIS Immunization Data means demographics and immunization <br />status of individual persons collected by IIS, regardless of whether in the form of raw data or appearing in other <br />IIS features and functions made available to my employer. <br /> <br />I will not share my unique IIS login code with anyone nor allow anyone to access IIS using my login code. <br /> <br />I will not at any time, nor in any manner, either directly or indirectly divulge, disclose, release, or communicate <br />any IIS Immunization Data to any third party unless specifically necessary to perform my assigned job duties, <br />required by law or authorized by the person, or parent or guardian of the person, to whom the IIS Immunization <br />Data applies. I recognize that maintaining confidentiality includes not discussing IIS Immunization Data outside <br />of the workplace. I will limit my own access to person-specific data in IIS to that which is necessary to perform <br />my job duties. <br /> <br />I understand that if I discuss, release, or otherwise disclose confidential data/information outside of the scope <br />of this policy through any means, I may be subject to disciplinary action, which may include termination of <br />employment. <br /> <br /> <br />Employee signature: Date: <br /> <br /> <br />Employee name (please print): <br /> <br /> <br />Received on (date): By: (supervisor’s signature): <br /> <br />A signed copy of this form must be on file with the Employer before employee may access IIS.