Medicare Tax Eligibility Form - River Parishes Community College Page 3
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4RIVER PARISHES COMMUNITY COLLEGE
CONFIDENTIALITY AGREEMENT
Statement of Confidentiality
The following guidelines represent the policy of the River Parishes Community College,
concerning the confidentiality of student records. The policy reflects current
interpretation of the Family Educational Rights and Privacy Act of 1974. It is intended to
serve as written statement of policy and upon annual publication and dissemination as the
notice of rights required by the regulation implementing the Act (45 C.F.R. Sections 99.5
and 99.6).
Not Disclosing Personally Identifiable Information
The records to which the college policy against disclosure applies are those defined
below. “Personally Identifiable Information” means that the data or information include
(a) the name of the individual, (b) the address of the individual, (c) a personal identifier
such as the individual’s social security number, or (d) a list of personal characteristics or
other information that would make the individual’s identity easily traceable. Other
information will include, and not limited by, student’s score and grades, incidental
comments and data found within student folders or institutional confines.
By signing this document, I
understand that I will
not discuss or divulge any of the student or institutional data that I am responsible for or
come in contact with. The worker aforementioned in this document may not discuss
confidential information in a place where such a discussion might be overheard. Neither
will the parties involved discuss confidential information in a way that would allow an
unauthorized person to associate (either directly or indirectly) an identity with such
information.
Student Signature
Date
Faculty Signature
Date
Staff Signature
Date
Campus Admin./Dean Signature
Date
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