Acknowledgment of Confidentiality Form SEC IM - filable.pdf
PDF 225 KB Posted
- Attached to
- Plumbing Services
- Solicitation number
- BPM058237
- Issued by
- Maryland
About this file
This is an Acknowledgment of Confidentiality Form issued by Clifton T. Perkins Hospital Center in Maryland for visitors, guest speakers, lecturers, and other non-media attendees participating in facility tours for informational and educational purposes. The form establishes the confidential nature of patient information and requires signatories to acknowledge their obligation to protect all patient data, including the mere fact of a patient's presence at the facility. Visitors must disclose any personal knowledge of or relationships with current patients of the hospital and agree to submit to security searches upon entry to the premises.
The form explicitly prohibits visitors from bringing alcoholic beverages, drugs, or weapons, including pocket knives, onto hospital grounds. Signatories acknowledge personal liability for any damages, costs, or claims arising from breaches of patient confidentiality or violations of the agreement terms, with liability extending to costs incurred by the hospital or state. The completed form must be returned to the Principal Investigator Director upon completion and requires printed name, date, and signature of the visitor before entry is granted.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| BPM058237 Plumbing Services RFB .pdf | ||
| Exhibit B-1 Bid Form.BPM058237.xlsx | XLSX spreadsheet | |
| Exhibit D Contractor Daily Report.xlsx | XLSX spreadsheet | |
| Exhibit C-Small Procurement Contract (Example).pdf | ||
| CTPHC Outside Vendor Tool Inventory Form (7).pdf | ||
| Contractor Safety Reference Sheet (8).pdf | ||
| Exhibit A. Contractor Construction Guidelines.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
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 |
File details come from the government source that posted it. Updated .