I, _________________ (employee name), acknowledge that I have access to sensitive data maintained by the [variable: Covered Organization] in its [variable: covered application/s or system/s] data applications.

I agree that I will obtain, use or disclose such data only in connection with the performance of my official duties solely for authorized purposes.

I agree to maintain the confidentiality of information in accordance with the [variable: Covered Organization] Regulations. (List Regulations)

I understand that failure to safeguard Sensitive data may result in the imposition of penalties, including fines, costs of prosecution, dismissal from office, discharge from employment, and imprisonment. [variable: Applicable federal, state, and local statute references].

If I observe any conditions, which could cause said information to be compromised in any way, I understand that it is my responsibility to take action to safeguard [variable: Covered Organization] data and report the incident to my manager.

I agree that my obligation to safeguard the confidentiality of [variable: Covered Organization] data shall survive the termination of my employment with [variable: Covered Organization].

ACKNOWLEDGED AND WITNESSED:

_______________________________________ Employee Signature

_______________________________________ Employee Name

_______________________________________ Supervisor or Witness Signature

_______________________________________ Supervisor or Witness Name

_______________________________________ Date