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Hospital IBRS/IDRS Confidentiality Agreement
The Indiana Birth and Death Registration Systems (IBRS/IDRS) are being implemented by the Indiana State Department of Health under the authority of Indiana Code: IC 16-37-1. All information in the systems is confidential, and all users have a responsibility to abide by confidentiality laws. Users who violate these laws will have access to the IBRS and the IDRS immediately revoked by the State Registrar. · · · · All users shall safeguard his/her user ID and password, and agree to not give a user ID and/or password to others, or to post a user ID and password on any place. Individual IBRS and IDRS passwords should be changed periodically to protect security. The system will prompt for a password change. The computer should not be left unattended when an IBRS or IDRS session is open. Always log off when you are finished with an IBRS or IDRS session.

By signing this form, the User acknowledges the conditions under which access to the IBRS and IDRS is granted, and agrees to be held to these conditions. Check the system(s) you need access to: IBRS IDRS

Facility Name: __________________________________________________________________ ______________________________________________________________________________ Print Employee Name Date (month, day, year) Employee Signature Employee e-mail: ________________________________ Telephone: ___________________ State issued drivers license or state ID number: _____________________________________ ______________________________________________________________________________ Site Manager's Name Date (month, day, year) Site Manager's Signature

Site Manager's e-mail: _____________________________ Telephone: ___________________

Assigned User ID (provided by ISDH): _________________________________________ Send completed form and a photocopy of your state issued drivers license or state ID to: Vital Records Department Indiana State Department of Health 2 North Meridian Street Indianapolis, IN 46204 OR fax to the IBRS/IDRS Support Center at 317-233-5956 Please copy additional sheets as necessary.
State Form 53756 (R2 / 5-09)