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Confidentiality Form

Clinical Simulation Center

Confidentiality Agreement

I have access to Confidential Clinical Simulation Center Information and need to be aware of and abide by procedures that apply to simulation information:

Confidential simulation information is defined as anything that I, or those individuals with whom I interact, would expect to remain private including information relating to

  • simulation patients;
  • standardized patients;
  • patient models; and
  • students

Confidential information may be used only as needed to perform my specific activity related responsibilities.

As a student, learner, trainee or patient actor, I am required to comply with the Clinical Simulation Center guidelines relating to confidential information. I understand that:

1. I may have access to confidential simulation information.

2. I am responsible for protecting all simulation information.

3. Confidential simulation information may only be used as needed to perform my assigned activities. I may:

a. not share any simulation scenario information with others outside of my clinical simulation group and clinical faculty;

b. not share or disclose specific simulation patient health information;

c. not share student performance with anyone other than those in my clinical simulation group and clinical faculty;

d. not misuse or be careless with simulation information.

4. Violating this Agreement may subject me to loss of simulation privileges.

5. Video recordings/photos may be used for follow-up instruction, orientation to the simulated environment, CSC tours, seminars, and RU simulation center website/RU Facebook page.

By signing below, I acknowledge that I have read and understand the above Agreement and agree to abide by the terms of this Agreement.

Signature ____________________________________

Date _________________________________________

Printed Name _________________________________

Organization __________________________________

Revised: May 2014