Acknowledgment of Confidentiality Form SEC IM - filable.pdf

225 KB Posted

Attached to
Piping and Recirculation Pump Repair in Central Kitchen Area
Solicitation number
BPM057647
Issued by
Maryland

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Written by GovTribe AI ·

This is an Acknowledgment of Confidentiality Form related to a procurement opportunity from Clifton T. Perkins Hospital Center in Maryland. The form establishes confidentiality requirements and protocols for parties involved in the bidding process for maintenance services in the Dietary area, specifically for repair of damaged piping and a recirculation pump in the central kitchen area. The document serves as a binding agreement whereby recipients acknowledge their understanding of confidential information restrictions and commit to maintaining the security of proprietary details shared during the procurement process.

The confidentiality form does not contain specific pricing, contract terms, site visit schedules, bid due dates, or award timelines. Rather, it functions as a preliminary administrative document that bidders or participants must complete and return to demonstrate their commitment to protecting sensitive information related to the hospital's operations and the procurement process. This form is typically required before access to detailed project specifications, technical documents, or other restricted materials is granted to potential contractors.

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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

File details come from the government source that posted it. Updated .