Acknowledgment of Confidentiality Form SEC IM - filable.pdf

PDF 225 KB Posted

Attached to
Supplemental Locksmith Services at Clifton T. Perkins Hospital Center
Solicitation number
BPM057776
Issued by
Maryland

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Written by GovTribe AI ·

This is an Acknowledgment of Confidentiality Form (IM Form #02, Rev. 11/11) for Clifton T. Perkins Hospital Center, a Maryland state facility. The form is required for guest speakers, lecturers, visitors, and tour attendees who access the hospital facility for information or educational purposes. Visitors must acknowledge their obligation to maintain strict confidentiality regarding all patient information, including the mere fact of a patient's presence at the facility. The form requires visitors to disclose any personal knowledge of or relationships with current CTPHC patients and authorizes hospital security to conduct searches of persons and property upon entry.

Signatories agree that breach of patient confidentiality will result in personal liability for all damages and costs arising from violations, including losses incurred by the hospital or the state. Visitors are prohibited from bringing alcoholic beverages, drugs, weapons, or pen knives onto hospital premises. The form must be completed and returned to the PI Director prior to facility access. This document serves as a prerequisite control measure related to the hospital's operations and is associated with the state contract opportunity for Supplemental Locksmith Services at Clifton T. Perkins Hospital Center.

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Other files

File Type Posted
Exhibit A. Contractor Construction Guidelines.pdf PDF
BPM057776 Supplemental Locksmith Services RFB.pdf PDF
CTPHC Outside Vendor Tool Inventory Form (7).pdf PDF
Exhibit C-Small Procurement Contract (Example).pdf PDF
Exhibit D Contractor Daily Report.xlsx XLSX spreadsheet
Exhibit B-1 Bid Form.BPM057776.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

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