CONFIDENTIALITY AGREEMENT FOR COVID-19 WORKFORCE

All information regarding the Mississippi State Department of Health (MSDH), its patients, clients, staff, and programs is considered confidential.

I,       first name                       middle name                      last name                           maiden name                                          ,

(First name – please print)                     (Middle name)                            (Last name)                                 (Maiden  name)  do hereby certify that I will not use or disclose any information regarding a MSDH patient or client, including information regarding the patient or client’s relatives, employers, or household members, that has been or may be disclosed to me. This includes, but is not limited to, any reference to the identity, physical location, financial information, and medical condition, treatment, diagnosis, or prognosis of a

MSDH patient or client, or the patient or client’s relatives, employers, or household members. Further, I do hereby certify that I will not unlawfully take or retain in my possession, any information regarding an MSDH patient or client or the patient or client’s relatives, employers, or household members, to which I may have access. Additionally, I do hereby certify that I will not use or disclose, take or retain any information or records maintained or received by MSDH as part of its efforts to track reportable diseases and control communicable disease outbreaks.

I am aware and agree that all information regarding an MSDH patient or an MSDH public health investigation that has been or may be disclosed to me may contain Personally Identifiable Information (PII) and/or Protected Health Information (PHI), and pursuant to federal law, state law, and MSDH policy, this information must be held in the strictness of confidence and not discussed with anyone.

I understand that a violation of this confidentiality agreement may subject me to penalties, including, but not limited to, dismissal from my role with MSDH and/or civil or criminal liability.

[Signature page follows.]

I certify that I have read and will comply with the above statement.

(Signature)                                                                                        (Date signed – mm/dd/yyyy)

(Mailing address)                                                                             (City)                                                                                                            (State)                                                                                                            (Zip)

(Email)                                                                                                (Telephone Number)