Winona State University

Athletic Training Education Program

Athletic Training Student Confidentiality Agreement

 

As part of your experiences as an undergraduate athletic training student at Winona State University , you will have access to information that is protected by various federal and state privacy laws. This information is known as not public data . Unauthorized disclosure of not public data includes releasing information over the telephone, in verbal conversations and in written form, without consent.

 

Types of not public data include: student/athlete addresses, phone numbers and email addresses, student/athlete social security or warrior ID numbers, student academic information, student/athlete medical information or family history information, student/athlete financial or insurance information, and faculty or ATC phone numbers, addresses, or ID numbers.

 

I, ______________________________, understand and agree that in the performance of my duties at _______________________________, I must hold medical, physician, volunteer, and employee information in confidence. This includes information that I may come across in performing my duties regardless of how it is presented to me (printed, written, spoken, computerized, facsimile, etc.). I also understand and agree that I will only access information that is required to perform my duties or for express educational purposes as approved by a Certified Athletic Trainer. I will not remove student/athlete data/forms from the athletic training facility, will keep student/athlete private information concealed, and I agree to follow established athletic training facility procedures for all paperwork. I understand violation of the confidentiality laws may result in federal action (imprisonment and fines), as well as removal from the WSU Athletic Training Education Program.

 

I further understand that any violation of the confidentiality of personal and private information of patients, physicians, volunteers or other employees may result in disciplinary proceedings up to and including dismissal from the program and/or legal action.

 

________________________________ ________________________ ____________

Print Name           Signature       Date