Microsoft Word 52736.doc


1 CONFIDENTIALITY AGREEMENT State Form 52736 (R2 / 6-11) DEPARTMENT OF CHILD SERVICES I, the undersigned, agree to maintain the confidentiality of any and all personally identifiable information, tment of Child Services or any agent or employee of concerning any individual, which I receive from the Depar the Department. I will not share or provide, in any manner, any confidential or personally identifiable information gathered, accessed, or obtained by me to any other person or agency without the express written consent of the Department. I understand and acknowledge that any and all information obtained during the course of my involvement with the Department of Child Services is CONFIDENTIAL, pursuant to Indiana Code 31-31-18 et seq . I understand that any unauthorized disclosure of any confidential and/or protected information may constitute a criminal mi sdemeanor for which I may be prosecuted. Signature Date (month, day, year) Printed name Signature of local office director or designee Date (month, day, year) Printed name of local office director or designee

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