Free ROSIE User Security and Confidentiality Agreement, DPH 40093 - Wisconsin


File Size: 30.1 kB
Pages: 1
Date: June 23, 2006
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS/DPH/BCHP/WIC
Word Count: 472 Words, 3,357 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/DPH/dph40093.pdf

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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40093 (06/06)

STATE OF WISCONSIN Bureau of Community Health Promotion

ROSIE USER SECURITY AND CONFIDENTIALITY AGREEMENT
User Name (print) User Role (check all that apply) Local ROSIE Project Administrator User's ROSIE I.D.

WIC Director

WIC staff

PH agency supervisor

Other PH agency staff

Other (specify): _____________________________________________________________________________________________ WIC Project Name Project Number WIC Local Project Administrator (ROSIE)

By signing this agreement, I agree to:
1. Comply with the Wisconsin WIC Program's Real-Time Online Statewide Information Environment (ROSIE) policies and my organization's standard policies and procedures for confidentiality and release of client-identifying information. WIC-specific policies are located in the WIC Operations Manual and are hereby referenced as 5.9, 10.41 and 11.11. These policies should be reviewed before signing this document. 2. Use ROSIE to document accurate demographic and health information data for the purpose of maintaining WIC client records. 3. Use ROSIE to enter timely and accurate WIC and other public health data, and to access information and generate individual, family and aggregate outcome data only as necessary to properly provide individual, household, community and system WIC and public health activities and interventions. 4. Carefully and deliberately safeguard my ROSIE user ID and password in accordance with WIC Program policies, as well as generally accepted security practices and my organization's policies and procedures. 5. Allow ROSIE State or Local Project Administrators, in coordination with CIBER, to audit any and all ROSIE transactions to ensure compliance with all applicable security and confidentiality policies. 6. Disclose identifying client information to other persons/agencies only as allowed by policies 5.9 and 10.41 (e.g., written client consent, as delineated by State and local memoranda of understanding with other programs, child abuse reporting, investigations of WIC crimes). 7. Promptly report to Local Project Administrator or State WIC Office Project Administrators any threat to, or violation of, this policy or any WIC security and confidentiality policies.

By signing this agreement, I agree to NOT:
1. Furnish identifying information or documentation obtained from ROSIE to any unauthorized person within or outside of the organization. (See Policies 5.9 and 10.41.) 2. Copy the ROSIE database or any associated software (including, but not limited to, individual queries and reporting databases) to personal computers or otherwise unauthorized non-agency computers. 3. Knowingly falsify any document or data obtained through or input into ROSIE.

I have read, understand, and agree to abide by this ROSIE Security and Confidentiality Agreement and the above requirements. I understand that, if I violate these or any other confidentiality or security requirements, my access to ROSIE data can be terminated and I may be subject to penalties imposed by law.
SIGNATURE - User Date Signed

Title of User (print)

SIGNATURE ­ Project Director (or Project Director's supervisor if this is the Director's Agreement)

Date Signed

Distribution: Original signed Agreements shall be maintained on file at the local project.