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ATTACHMENT B <br />11S Confidentiality Agreement <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 ("11S"). My employer has made a copy of the Agreement <br />available to me. <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. 11S Immunization Data means demographics and Immunization <br />status of Individual persons collected by 11S, regardless of whether In the form of raw data or appearing in other <br />1IS features and functions made available to my employer. <br />I will not share my unique IIS login code with anyone nor allow anyone to access 11S using my login code. <br />I will not at any time, nor in any manner, either directly or indirectly divulge, disclose, release, or communicate <br />any 11S 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 11S Immunization <br />Data applies. I recognize that maintaining confidentiality includes not discussing 11S 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 />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 />Employee signature: Date: <br />Employee name (please print): <br />Received on (date): By: (supervisor's signature): <br />A signed copy of this form must be on file with the Employer before employee may access I IS . <br />Page 7 of8 <br />If you have a disability and need this document in another format, please call l-800-525-0127 (711-TTY relay). <br />DOH 348-576 November 2017