"Oath of Confidentiality for Center Staff

[Instructions: Statement must cover the responsibility not to wrongfully release confidential information/records and the performance/civil/criminal penalties that may be associated with wrongful rerelease.]

I, the undersigned, hereby agree not to divulge any information or records concerning any Center program participant without proper authorization in accordance with state and federal law and interagency agreement(s). I recognize that any discussion of or release of information concerning a participant to any unauthorized person is forbidden and may be grounds for legal and/or disciplinary action.

During the performance of my assigned duties, I will have access to confidential information required for effective family services coordination and delivery. I agree that all discussions, deliberations, records, and information generated or maintained in connection with these activities will not be disclosed to any unauthorized person.

I recognize that unauthorized release of confidential information may expose me to civil/criminal liability and fine under __________________________________ [Instruction: Give legal citations].

Executed this _____ day of ____________, 19___, at ______________________.

Signature_______________________ Name (Print) _______________________

Received by:

Name of Center Coordinator or Designee ________________________

Title______________________ Date_____________________"