Acknowledgment of Confidentiality Form SEC IM - filable.pdf

225 KB Posted

Attached to
Re-Solicitation of Supplemental Locksmith Services
Solicitation number
BPM057997
Issued by
Maryland

About this file

Written by GovTribe AI ·

This is an Acknowledgment of Confidentiality Form related to a re-solicitation of Supplemental Locksmith Services from Clifton T. Perkins Hospital Center in Maryland. The form establishes confidentiality requirements that bidders and their representatives must acknowledge and comply with as a condition of participating in the procurement process. The document outlines the contractor's obligation to maintain confidentiality regarding proprietary information, technical data, and other sensitive materials disclosed during the solicitation and contract execution phases.

The confidentiality acknowledgment form serves as a binding agreement between Clifton T. Perkins Hospital Center and bidding entities, requiring signatories to protect confidential information from unauthorized disclosure or use. Bidders must sign and return the completed form as part of their proposal submission to demonstrate their commitment to maintaining the confidentiality standards established by the hospital center. This procurement carries a small business preference designation, meaning eligible small businesses receive consideration priority in the award process.

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File Type Posted
Contractor Safety Reference Sheet (8).pdf PDF
Exhibit C-Small Procurement Contract (Example).pdf PDF
CTPHC Outside Vendor Tool Inventory Form (7).pdf PDF
Exhibit B-1 Bid Form.xlsx XLSX spreadsheet
BPM057997 Re-Solicitation of Supplemental Locksmith Services RFB.pdf PDF
Exhibit D Contractor Daily Report.xlsx XLSX spreadsheet

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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 .