Confidentiality Agreement: Student Observer/Assistant
I understand that in the performance of my duties as a student observer and/or assistant at
Sacred Heart University Audiology Clinic, operating under Sacred Heart University, Inc., I may
have access to and/or be involved in the gathering or processing of confidential information
about persons receiving services and/or confidential business information.
Confidential information pertaining to persons receiving services including all
information, whether spoken, written, or electronic, concerning their condition, events
surrounding their placement, and financial support for services provided.
Confidential business information whether spoken, written or electronic pertaining to
Sacred Heart University Audiology Clinic business plans, employee information, and
other information related to Sacred Heart University Audiology Clinic operations.
I understand that I am required to maintain the confidentiality of this information at all times,
both on and off-campus, and after the termination of my enrollment as a student at Sacred
I also understand and agree that I will only access information which is needed or required by
the supervisor at the Sacred Heart University Audiology Clinic, federal, or state law, or
I understand that a violation of these confidentiality considerations may result in disciplinary
action. I further understand that I could be subject to legal action for breach of confidentiality.
I have discussed confidentiality of information directly with my supervisor and have had the
opportunity to ask any questions I may have regarding my responsibilities as related to HIPAA
and confidentiality of information.
Student Name (Printed) Date
Student Name (Signed) Date