Student Application Form (Page 4 of 4) in pdf

Student Application Form Page 4

Volunteer Nondisclosure Agreement

Reutlinger Community for Jewish Living

Reutlinger Community for Jewish Living has a legal and ethical responsibility to

safeguard the privacy of all residents and to protect the confidentiality of their

health information. In the course of my employment/assignment at Reutlinger

Community for Jewish Living (RCJL), I may come into possession of confidential

resident information, even though I may not be directly involved in providing

resident services.

I understand that such information must be maintained in the strictest confidence.

As a condition of my employment/assignment, I hereby agree that, unless

directed by my supervisor, I will not at any time during or after my

employment/assignment with RCJL disclose any resident information to any

person whatsoever or permit any person whatsoever to examine or make copies

of any resident reports or other documents prepared by me, coming into my

possession, or under my control, or use resident information, other than

necessary in the course of my employment/assignment.

When resident information must be discussed with other healthcare organization

staff in the course of my work, I will use discretion to ensure that others who are

not involved in the resident’s care cannot overhear such conversations.

I understand that violation of this agreement may result in corrective action, up to and including

termination of my employment/assignment.

________________________________

_____________________

Signature of Volunteer

Date

________________________________

Print Name

Feb 2013

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Student Application Form Page 4