Confidentiality Statement for the Multi-Disciplinary

CONFIDENTIALITY STATEMENT FOR THE MULTI-DISCIPLINARY

MATERNAL MORTALITY REVIEW COMMITTEE

The Colorado Department of Public Health and Environment (CDPHE) acknowledges a legal and ethical responsibility to protect the privacy of confidential information that it collects, uses and maintains. CDPHE oversees the efforts of boards and committees that support its public health mission. It is the responsibility of board and committee members to preserve and protect all CDPHE confidential information.

The purpose of the Maternal Mortality Review Committee is to conduct a full examination of all pregnancy-associated deaths (both pregnancy-related and non-pregnancy-related) in Colorado. In order to assure a coordinated response that fully addresses all systemic concerns surrounding a particular incident, the Maternal Mortality Review Committee must review all pertinent information on each death. This includes reviewing de-identified autopsy reports, coroner’s reports, law enforcement reports, hospital and prenatal care records, and other information that may have a bearing on the involved family.

With this purpose in mind, I the undersigned, as a representative of

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I understand that as a member of the Maternal Mortality Review Committee, I have a personal, professional, ethical and legal obligation to uphold these principles of confidentiality, privacy and information security, and will abide by the following standards:

• No materials with case identifying information will be taken from the meeting;

• I shall obey all applicable federal and state laws and regulations pertaining to confidentiality and data privacy and security requirements;

• I shall not review, discuss, copy or use confidential information not related to my work on the committee;

• I shall not disclose confidential information to unauthorized persons who do not have a legitimate need to know such information, unless such person has been authorized to have access to such information;

I understand that any violation of this confidentiality agreement will be considered a breach of my obligations.This may lead to termination of my participation on the Maternal Mortality Review Committee and other remedies allowed by law. Additionally, unauthorized disclosure of confidential information may result in civil or criminal sanctions.

I acknowledge that I have read and understand the above statements.

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Print Name

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Signature

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Date

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Witness Rev. 09/2014