Acknowledgment of Confidentiality Form SEC IM - filable.pdf

PDF 225 KB Posted

Attached to
Canine Contraband Detection Services
Solicitation number
BPM059096
Issued by
Maryland

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Written by GovTribe AI ·

This is an Acknowledgment of Confidentiality Form issued by Clifton T. Perkins Hospital Center, a Maryland state facility, for visitors attending tours or presentations at the hospital. The form establishes confidentiality obligations for guest speakers, lecturers, and other visitors who access the facility for informational or educational purposes. Signatories must acknowledge that all information learned regarding patients or evaluees, including their presence at the hospital, is strictly confidential and cannot be disclosed. The form requires visitors to disclose any personal knowledge of or relationships with current patients of the hospital, listing specific patient names and explaining the nature of any such relationships.

The form establishes personal liability for breach of patient confidentiality, with signatories subject to damages and costs resulting from any violations or claims arising from the unauthorized release of information. Visitors are also notified that they may be subject to searches of their person and property by Hospital Security and are prohibited from bringing alcoholic beverages, drugs, or weapons, including pocket knives, onto hospital premises. The completed form must be returned to the PI Director upon completion, serving as a binding acknowledgment of the confidentiality obligations and facility rules associated with visiting Clifton T. Perkins Hospital Center.

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IM Form #02 Rev. 11/11 SEC – Visitors: Others

CLIFTON T. PERKINS HOSPITAL CENTER

ACKNOWLEDGEMENT OF OBLIGATION

OF CONFIDENTIALITY

I, of , am a guest speaker/ lecturer/ visitor attending a tour of Clifton T. Perkins Hospital Center for information/ educational purposes. I am not a member of the print or electronic media. I understand and acknowledge that any information I learn regarding [any] patient, or evaluee, including the fact that a patient or evaluee is in the hospital, is confidential and may not be released. If I should breach, or be accused of violating patient confidentiality, I will be personally liable for any damages and costs from any claim or cause of action arising from such conduct, including all costs, damages to the Hospital or State that may result from or arise in connection to the tour and release of information.

I further understand I may be subject to a search of person and property by Hospital Security, and agree not to bring any alcoholic beverages, drugs, or weapons, including a pen knife onto the Hospital premises.

PRINT NAME DATE SIGNATURE

PATIENT KNOWLEDGE DISCLOSURE

Please check the appropriate box:

No, I have no personal knowledge of and/or personal relationship with any patient of CTPHC.

Yes, I have personal knowledge of and/or a personal relationship with the following CTPHC patients:

Name: Name:

Name: Name:

Name: Name:

Please explain personal knowledge of and/or type of relationship:

PRINT NAME DATE SIGNATURE

RETURN TO PI DIRECTOR UPON COMPLETION

CLIFTON T. PERKINS HOSPITAL CENTER
ACKNOWLEDGEMENT OF OBLIGATION
OF CONFIDENTIALITY
I, of , am a guest speaker/ lecturer/ visitor attending a tour of Clifton T. Perkins Hospital Center for information/ edu...
I further understand I may be subject to a search of person and property by Hospital Security, and agree not to bring any alcoholic beverages, drugs, or weapons, including a pen knife onto the Hospital premises.
PRINT NAME DATE SIGNATURE
PATIENT KNOWLEDGE DISCLOSURE
Please check the appropriate box:
No, I have no personal knowledge of and/or personal relationship with any patient of CTPHC.
Yes, I have personal knowledge of and/or a personal relationship with the following CTPHC patients:
Name: Name: Name: Name:
Name: Name:
Please explain personal knowledge of and/or type of relationship:
PRINT NAME DATE SIGNATURE
RETURN TO PI DIRECTOR UPON COMPLETION
PRINT NAME:
DATE:
Name:
Name_2:
Name_3:
Name_4:
Name_5:
Name_6:
Please explain personal knowledge of andor type of relationship 1:
Please explain personal knowledge of andor type of relationship 2:
Please explain personal knowledge of andor type of relationship 3:
Please explain personal knowledge of andor type of relationship 4:
PRINT NAME_2:
DATE_2:
Your Name:
Company You Represent:
Check Box4: Off
Check Box3: Off

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