Confidentiality Agreement

2. 

4. The New Hanover County Senior Resource Center policy regarding confidentiality of citizen information is in accordance with laws which specifically address confidentiality (GS 130A-12, GS 130A-143, GS130A-212). All information concerning citizens is strictly confidential and should only be discussed or shared:

   • With those specifically authorized by written consent of the citizen, or others authorized to give consent for the citizen;
   • When necessary to provide appropriate care (within our agency) except as described in GS 130A-143;
   • Pursuant to subpoena or court order.

   Failure to observe the policy regarding confidentiality is reason for suspension or dismissal and may subject the employee, student, volunteer or contract worker to a lawsuit. All employees, students, volunteers, and contract workers will be required to sign a statement of understanding regarding this policy.

   • I understand that I may have direct or indirect access to confidential individually identifiable personal information (IIPI) in the course of performing my work activities.
     • Note: IIPI is any information collected from an individual that is created or received by the NHCSRC and relates to past, present or future contact, beneficiary, or individually identifiable information. Protected personal information (PPI) is IIPI in any form: paper, oral or electronic, that personally identifies an individual.
   • I agree to protect the confidential nature of all IIPI to which I have access and will not divulge this information to unauthorized persons.
   • I understand that there are state and federal laws and regulations that ensure the confidentiality of an individual’s identifying personal information.
   • I understand that there are New Hanover County Senior Resource Center (NHCSRC) policies and procedures with which I am required to comply related to the protection of IIPI.
   • I understand that my failure to observe and abide by these policies and procedures may result in disciplinary action, which may include dismissal, contract termination, and/or punishment by fine and/or imprisonment.
   • I understand how I am expected to ensure the protection of IIPI. Should questions arise in the future about how to protect information to which I have access, I will immediately notify my supervisor and/or the NHCSRC Director.
   • I have been informed that this signed agreement will be retained on file for future reference.
6. First Name*
7. Last Name*
8. Email
10. Consent*

    1. I agree to this confidentiality agreement.
12. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
14. Electronic Signature*
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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