Sample Confidentiality Agreement Template

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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
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.
I have read, understood, and agree to comply with the confidentiality policy described
above.
____________________________________
_______________________________
Signature
Print Name
Date: ______________________________

Download Sample Confidentiality Agreement Template

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