St. Jude Children's Research Hospital Family-Centered Care Confidentiality Agreement

Asterisk (*) indicates a required field.

First Name*

Last Name*

As a workforce member (as defined under HIPAA) of St. Jude Children's Research Hospital (SJCRH), I understand that I may have access to certain confidential, health, financial, proprietary, research, patient or operational information of SJCRH, its employees and the patients and their families (collectively known as "Confidential Information"). I further acknowledge that SJCRH has a legal and ethical obligation to protect this Confidential Information. This same obligation applies to me while as a member of the Family-Centered Care program.

In recognition of this responsibility, which constitutes an essential function as a member of the Family-Centered Care program, I agree as follows:

1. All Confidential Information at SJCRH shall be treated as confidential. I will not access or seek to gain access to Confidential Information of any nature whatsoever except in the course of fulfilling my responsibilities.

2. I agree not to discuss patient, human resources, payroll, fiscal, research or business information or other Confidential Information where others can overhear the conversation, e.g., in hallways, on elevators, in the cafeterias, on the shuttle buses, on public transportation, at restaurants, at social events. It is not acceptable to discuss clinical or patient information in public areas even if a patient's name is not used. This can raise doubts with patients and visitors about our respect for their privacy.

3. If, in the course of performing my responsibilities, I accidentally access information or Confidential Information that might be considered inappropriate for me to access, I will notify [my supervisor] immediately of the date and time of the access so that if a question arises at a later time, it will be understood that the access was accidental. I will not disseminate any such information without proper authorization.

4. I will not use another person's sign-on or computer password or allow another individual to use my sign-on or computer password to gain access to Confidential Information or information which may be considered confidential without proper authorization. I will not disclose Confidential Information to those who are not authorized to receive it. In addition, I will not, without proper authorization, copy or preserve in written, electronic, or any other form Confidential Information, nor will I disseminate any such information without proper authorization. If I am in doubt about whether the authorization provided is "proper", I will consult an Information Security department representative for guidance. These obligations shall continue both during and after termination of membership on Family Advisory Council or as a member of the Family-Centered Care program with St. Jude Children's Research Hospital.

5. I understand that I am responsible for all activity logged under my username and that I should always lock or log off of any computing device prior to leaving the device unattended. I agree to follow SJCRH's E-mail, Internet and Electronic Protected Information policies, which include all use of Social Media (e.g. Twitter and Facebook).

6. Violation of this Agreement may subject me to corrective action, up to and including termination, as well as penalties and legal action by state and/or federal agencies.

My initials below acknowledge that I understand the obligations imposed upon me by this Agreement, and I agree to comply with all the terms of this Agreement.

Initials*

Date Submitted*

I agree to share this information with St. Jude*
This Service is governed by and operated in accordance with US law. If you are located outside of the US, you use this Service voluntarily and at your own risk. If you choose to submit personal data like your name and email address, please note that your Information will be transferred to and processed in the United States. By checking this box while using this Service, you acknowledge that the data protection and other laws of other countries, such as the United States, may provide a less comprehensive or protective standard of protection than those in your country, and consent to your Information being collected, processed and transferred as set forth in the Privacy Policy and US law.