Confidentiality Agreement - CHEO

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Confidentiality Agreement

During my affiliation with CHEO, I may have access to information and material relating to patients, physicians, employees, other individuals, or corporate information, which is of a private and confidential nature.

Affiliation with CHEO

High School Co-op Student

Volunteer

Other

If other, please indicate:

By checking the boxes below and completing this form, you agree to the following requirements and understand they will remain in force even if you cease to have an affiliation wh CHEO:

I acknowledge that I understand CHEO’s policies « Privacy and Confidentiality of Patient Personal Heath Information » (no 10) and « Freedom of Information and Protection of Privacy Act (FIPPA) » (no 596) as explained and outlined in the Manual.

It is my legal and ethical responsibility to respect the privacy and confidentiality of patients, employees, and all associated individuals. This includes all CHEO administrative, financial, patient, employees, research and other records.

I shall ensure the safekeeping of confidential information and ensure it is not inappropriately accessed, used, or released either directly by me, or by virtue of my signature or security access to premises or systems. I will only access information that is required for the purpose of my affiliation.

I will not disclose or discuss confidential personal health information and/or personal information except to authorized individuals or entities that are authorized to receive such information.

Any unauthorized disclosure or breach of privacy on my part will be considered to be a serious offense, including disciplinary action up to termination of my affiliation with CHEO.

I understand that CHEO may conduct periodic audits to ensure compliance with this agreement.

I have read the above statements, required policies and I understand that failure to comply with these requirements during and beyond my affiliation could result in disciplinary, civil, and/or criminal legal action.

By submitting this form, I acknowledge that this agreement continues in perpetuity following my affiliation with CHEO.

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