Attachment G Confidentiality Statement.docx

IOWA DEPARTMENT OF HEALTH AND HUMAN SERVICES

CONFIDENTIALITY STATEMENT FOR VENDORS’ EMPLOYEES AND SELF-EMPLOYED PERSONS

PERFORMING JANITORIAL SERVICES

I, , am:

(Print Name) (Check one) An employee of____________________________________________________________________(“Vendor”) (Print Vendor Name, if applicable) Self-employed, and do hereby agree to the terms and conditions of the Iowa Department of Health and Human Services (HHS) Confidentiality Statement as it pertains to the Vendor’s/my provision of janitorial services for HHS’s facilities, of which services may be directly contracted for between HHS and the Vendor/me, or between a third party and the Vendor/me.

1. I acknowledge and understand that HHS maintains confidential information on its premises. I acknowledge and understand all information recorded, obtained, or maintained by HHS is confidential. I understand confidential information may be visible to me in HHS facilities while I perform my responsibilities to provide janitorial services for HHS. I further acknowledge and understand that state and federal laws impose civil and criminal penalties for my viewing or disclosing of confidential information, for example, see Iowa Code § 252B.10.

2. I agree that I will not access, view, copy, remove or disclose confidential information recorded, obtained or maintained by HHS, and I understand that if I do, one or more of the following will happen: My immediate removal from access to HHS’s facilities; HHS’s refusal to allow me to work in any HHS facility; termination for cause of any such service contract HHS may have with me; immediate referral of the incident to the Vendor with a request for the Vendor to terminate my employment or risk breach of the janitorial service contract, if services are contracted for directly between HHS and the Vendor; immediate referral of the incident to the party contracting for the Vendor’s/my services, if other than HHS.

3. I understand that I will have access to HHS facilities only if I acknowledge and agree to adhere to the above and also to all following conditions.

a. I shall not access or use HHS computers or HHS computer-related equipment or storage devices or any HHS-utilized network for any purpose, because HHS computers and networks contain confidential information.

b. I shall not view confidential information, in paper form, about anyone receiving HHS’s services, and shall not access confidential information about people out of curiosity, including people I have heard of or know personally.

c. I shall not disclose confidential information to anyone, including but not limited to friends, spouse, relatives or the Vendor’s/my other employees. Confidential information includes but is not limited to an individual’s social security number, residential and mailing addresses, employment information and financial information.

d. I acknowledge I am bound by state and federal confidentiality law that prohibits or restricts obtaining or disclosing state and federal data and program information. For example, see Iowa Code § 252B.9. Some of these statutes carry criminal penalty or civil liability for statute violation. For example, see Iowa Code § 252B.10, 42 U.S.C. §§ 653(l)(2) and 654a(d)(5) and 5 U.S.C. § 552a.

e. I understand, acknowledge and agree that this Iowa Department of Health and Human Services HHS Confidentiality Statement remains in full force and effect after the conclusion, termination, or expiration of my work responsibilities with respect to services performed on behalf of the Vendor/me or third party for HHS.

(Check one)

I have read and understand the terms of this Confidentiality Statement, and I will comply with my responsibilities stated above.

OR

______________________________________________ (Print Name) read this Confidentiality Statement to me.

I understand the terms of this Confidentiality Statement, and I will comply with my responsibilities stated above.

Dated the day of , 20

Signature

FOR HHS USE ONLY Vendor: HHS Contract # Third Party Office:

(Rev. 04/2024) Page 2 of 2