Workforce Confidentiality Agreement

WORKFORCE CONFIDENTIALITY AGREEMENT

I understand that I may have access to information that is confidential and may not be disclosed except as permitted or required by law and by Mills-Peninsula Health Services policies and procedures. This information includes, but is not limited to, protected health information, personnel information and business operations information. I understand that I am committed to protect and safeguard from disclosure all confidential information regardless of the type of media on which it is stored (e.g. paper, micro-fiche, voice tape, computer systems). I agree that I will not disclose any confidential information from any record or information system to any unauthorized person.

I understand that:

• I am obligated to hold confidential information in the strictest confidence and not to disclose the information to any person or in any manner that is inconsistent with applicable law or the policies and procedures of Mills-Peninsula Health Services.

• I acknowledge that I may not use or disclose any confidential records of a friend, relative, staff member, volunteer or any other person, unless I am authorized to do so and am required to do so as part of my official duties. Such use and disclosure must be restricted to that required for essential business purpose(s).

• I will not discuss or allow confidential information of any type to be displayed or overheard in the proximity of any individual who does not have the right or need to know. This includes conversations in public places or private spaces where they may be easily overheard, allowing computer screens to be inappropriately visible, and leaving printed material where it may be openly viewed.

• In order to access certain information, a unique User ID, Security Code, Password, Access Device or Biometric ID may be established that identifies me to Mills-Peninsula Health Services Information Systems. My authentication codes and devices are for my use only when accessing facilities, systems and information appropriate to my work (although my supervisor or other authorized personnel may have access to such codes). To use anyone else's authentication code or device in order to access any Mills-Peninsula Health Services system is considered a violation of Mills-Peninsula Health Services confidentiality and security standards.

• All information obtained from Mills-Peninsula Health Services systems remains the property of Mills-Peninsula Health Services regardless of physical location or method of storage, unless otherwise specified by Mills-Peninsula Health Services in writing.

• If I believe that information confidentiality or security may be compromised in any way, either through the possible disclosure of sign-on information or the direct unauthorized access of information, either intentional or accidental, I shall contact my direct supervisor and/or the Sutter Health Compliance Department as soon as possible.

• User accounts or access to electronic information may be disabled without prior notice by the Chief Data Security Officer, Chief Information Officer or their designee when, in their opinion, they hold a reasonable belief that a user’s account may be compromised or is being used for inappropriate access to information.

• I understand that my privileges are subject to periodic review, revision, and if appropriate, renewal. I understand that all access to Mills-Peninsula Health Services systems is subject to monitoring and review as deemed appropriate by them.

• If at any time I feel that the confidentiality of my password(s), sign-on(s) or identification device(s) has been compromised, I will notify the Sutter Health Help Desk immediately so that my old code(s)/device(s) can be cancelled and new ones issued.

• My confidentiality obligation continues indefinitely.

• This Agreement does not supercede any other rules or expectations regarding the use or disclosure of confidential information that may be contained in other Mills-Peninsula Health Services documents. Such documents include, but are not limited to, job descriptions, policies, employee handbooks and department procedures.

I understand that any access, attempted access, or disclosure of information in violation of law or Mills-Peninsula Health Services policies will be considered a breach of confidentiality. I understand that if I breach such confidentiality, I may be subject to immediate disciplinary action, up to and including termination.

DECLINATION FOR 2010-2011 INFLUENZA VACCINATION

Mills-Peninsula Health Services has recommended that I receive the influenza vaccination in order to protect myself and the patients under my care. I acknowledge that I am aware of the following facts:

- Seasonal Influenza is a serious respiratory disease that kills an average of 30,000 Americans per year.

- Influenza virus may be shed up to 48 hours before symptoms begin, allowing transmission to others.

- Up to 30% of people with influenza have no symptoms, allowing transmission to others, and some people infected with influenza may develop a serious respiratory illness that may be fatal.

- Influenza vaccine cannot transmit influenza and does not cause “the flu”.

- If I am vaccinated, I will have a lower likelihood of acquiring influenza during this flu season.

- This year’s seasonal influenza vaccine contains the H1N1 strain that circulated last year, so only one influenza vaccination is required this year.

- Repeat vaccination for influenza are recommended each year as the immunity after vaccination declines after several months, and the strains of influenza in the vaccine are changed frequently.

- If I develop influenza, I will not be allowed to work at Mills-Peninsula Health Services for at least 7 days or until I am no longer contagious, even if I feel well.

- The consequences of my refusing to be vaccinated could endanger my health and the health of those with whom I have contact, including patients at Mills-Peninsula, my co-workers, my family and others in my community.

Despite these facts, I am choosing to decline influenza vaccination for the 2010-2011 seasons at this time. I acknowledge that influenza vaccine are recommended by the CDC (Centers for Disease Control and Prevention) for all healthcare personnel to prevent infection from and transmission of influenza, and its complications, including death to my patients, my coworkers, my family and my community. I understand that I can change my mind at anytime and accept the vaccine (if still available) at no charge.

I have read and fully understand the information of this declination form.

I am declining because: (please check all that apply)

HEPATITIS B VACCINE DECLINATION

I understand that my risk of exposure to blood or other potential infectious materials is minimal. I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B, I can retrieve the vaccine series from my health care provider.

Declination of Tetanus & Diphtheria/Pertussis Vaccination (Tdap)

I understand that due to occupational or other exposure, I may be at risk of contracting pertussis (whooping cough). I decline the Adacel vaccination at this time. I understand I must adhere to hospital infection control policies for the management of pertussis.

Please check all that apply: