Con114 - Confidential Information Form Page 2

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CONFIDENTIAL
3. Portions of juvenile protection case records that identify reporters of abuse or neglect
Reporter 1:
Reporter 2:
Reporter 3:
4. Information that a person has undergone HIV testing and/or HIV test results
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Other information that is confidential by statute, rule, or court order
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Filed by:
Name:
Signed:
Attorney Reg. #: (if attorney)
Firm/Agency Name:
Address:
City/State/Zip Code:
E-mail address :
Date:
CON114
State
ENG
8/15
Page 2 of 2

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