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Volunteer Sign-Up Form

I agree


During your service as a Volunteer for the Town of Marblehead (“Town”), you may obtain certain confidential information. The purpose of this agreement is to help you understand your obligations regarding such information.

“Confidential Information” means information that is not commonly available to the general public, or that isrequired by Federal or State laws or regulations, including, without limitation, the Health Information Portabilityand Accountability Act (“HIPAA”), the Commonwealth’s Department of Public Health regulations, and anyapplicable Town policies to be protected from disclosure to third parties. Generally, such information includes, without limitation, any individual’s health information that is used, maintained, stored, or transmitted in connection to the provision of healthcare or payment for healthcare services; and such individual’s common identifiers, including, without limitation, such individual’s name, address, birth date, or social security number and any other information which would be covered under privacy laws.

The intent of these laws, regulations, standards, and policies is to ensure that confidential information will remain confidential; that is, that it will be used only as necessary to accomplish the purpose for which it is needed and not be disclosed to third parties. You are therefore required to conduct yourself in strict conformance with all applicable laws, standards, regulations, and Town polices governing confidential information. Volunteers who violate any of these rules may be terminated. In addition, violation of these rules may result in civil and/or criminal penalties under HIPAA and/or any other applicable Federal or State law or regulation.

As such, in the event that you obtain confidential information, you hereby agree as follows:

  1. (a)  You will only use confidential information to the extent necessary to serve as a Town Volunteer;
  2. (b)  You will not divulge, copy, release, sell, or loan any confidential information unless you are explicitly authorized by your supervisor;
  3. (c)  You will not misuse or be careless with confidential information;
  4. (d)  You will report activities by any individual or entity that you suspect may compromise confidential information to your supervisor;
  5. (e)  Your obligations under this Agreement will survive the termination of your role as a Town Volunteer;
  6. (f)  You have no right or ownership interest in any confidential information;
  7. (g)  You will be responsible for your misuse or wrongful disclosure of confidential information and for your failure to safeguard confidential information; and
  8. (h)  The Town may initiate legal action including, without limitation, civil action or criminal prosecution in the event you violate this Agreement.

I certify that I have read and understand the Confidentiality Statement printed above and hereby agree to be bound by it. I also understand that compliance with the terms, principles, policies, and procedures set forth above is a condition of my service as a Town volunteer.