Sample Confidentiality Agreement printable pdf download

Sample Confidentiality Agreement

I understand that any information concerning the identities and information shared by people

participating in project-related focus groups, individual interviews, or other needs assessment

activities is to be kept confidential at all times.

The only exceptions to the above confidentiality policy are as follows:

1. When __________________________________ (agency) is bound by the law to report

suspected child abuse, elder abuse, and/or the abuse of a person with a disability and/or

homicide or homicidal or suicidal threats.

2. __________________________________ (agency) will comply with court orders and

properly issued subpoenas.

3. When __________________________________ (agency) staff are bound by state law

requirements to report abusive, illegal, or sexually exploitive acts by other mental health

professionals or organizations.

4. __________________________________ (agency) staff may discuss confidential

information about focus group and individual interviews with other project staff who have

signed confidentiality agreements.

Sample Confidentiality Agreement