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F-QM-005-A-V0 — Confidentiality Agreement Form

Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.

Parent document: LAB-QM-005 — Confidentiality Policy (parent is encoded in the form number)

Rendered in-browser from the project's Word file F-QM-005-A-V0-confidentiality-agreement-form.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.

Document #	F-QM-005-A-V0	Parent Document	LAB-QM-005 — Confidentiality Policy

Part 1 — Individual Undertaking the Agreement

Field	Entry
Full Name
Category (check one)	[ ] Employee [ ] Visitor [ ] Authorized Service Personnel [ ] Contractor
Position / Role (if employee)
Company / Institution (if non-employee)
Date of Orientation on the Confidentiality Policy (LAB-QM-005)

Part 2 — Agreement Declaration

I confirm that I have received orientation on the Tarangnan Community Hospital Clinical Laboratory Confidentiality Policy (LAB-QM-005). I understand that I must protect the confidentiality and privacy of patient information, and that I shall not disclose confidential information except as permitted or required by law and hospital policy.

I understand that breaking this agreement may lead to disciplinary action, up to and including termination, and to civil and/or criminal liability under Philippine law, including the Data Privacy Act of 2012 (RA 10173).

This obligation continues after my access to the Laboratory ends.

Field	Entry
Signature
Date Signed

Part 3 — Processing Record (completed by the Chief Medical Technologist / Laboratory Quality Manager)

Field	Entry
Oriented by
Form explained / questions addressed (Y/N)
Filed in (employee personnel file / Confidentiality binder)
Date Filed