Fillable Printable Sample Confidentiality Agreement Template

Sample Confidentiality Agreement Template

Sample Confidentiality Agreement

Confidentiality Agreement

I. Purpose. The purpose of this Confidentiality Agreement is to protect the identity and privacy of our

clients. Staff and Volunteers at the Agency encounter personal and sensitive information about clients.

This is particularly true when assisting immigrant survivors of domestic violence, human trafficking,

torture and persecution, and unaccompanied immigrant children. Therefore, it is very important to refrain

from disclosing any information to third parties about our clients to avoid causing them harm.

II. Confidential Information. Confidential client information should never be discussed in the presence of

third parties, except under the Terms outlined below. Any files and/or documents containing confidential

information should never be shared or released to third parties, except under the Terms outlined below.

Confidential information includes, but is not limited to, the following:

1. Identifying information about the client, including name, address or phone number;

2. Information relating to the client’s family;

3. Information regarding the client’s immigration status;

4. Information about the abuse, trauma, and/or persecution experienced by the client; or

5. Any other information that would identify the client or potentially place the client and/or

family members at risk.

III. Terms. By signing this Confidentiality Agreement, you agree to the highest ethical standards and to abide

by the following provisions:

1. All communications between Agency staff, volunteers, and clients are confidential.

2. The staff or volunteer shall not disclose confidential information to a third party without the

client’s express consent to release such information.

3. The staff or volunteer shall not disclose confidential information to a third party without

Agency’s knowledge and consent.

4. I understand that as a staff or volunteer, I have a duty to keep client information confidential

throughout my term as a staff or volunteer as well as after my employment or volunteer status

ends.

5. I understand that my failure to abide by the terms of this Confidentiality Agreement may

result in the termination of my participation as a staff or volunteer at the Agency.

(print name), have read the above the Agency’s

Confidentiality Agreement and understand its terms and my responsibilities as a volunteer.

Signature of Staff or Volunteer Signature of Supervisor Date