I, _______, certify that I have received and read the following Washington University and School of Medicine policies governing academic and non-academic transgressions and the AHBR policy on Academic Encumbrances:

By signing this statement, I agree to abide by the rules and regulations outlined in the policies listed above. I recognize that any suspected breach of professional or academic conduct will be reviewed by the AHBR Program Director, and, if necessary, brought before the AHBR Program Committee.


As an Non-Appointee of Washington University School of Medicine, you may come in contact with information which is both personal and confidential. It is your responsibility to treat all such information pertaining to the business of the Department/University, patients and other employees/non-appointees as “CONFIDENTIAL” and in the strictest confidence.

A patient’s medical record(s) and patient accounts information is to be considered “CONFIDENTIAL”. When it is necessary to discuss such matters in the course of your work, the discussion should be held in an appropriate place and manner. Under no circumstances should patient information be discussed with other employees or outside parties without direct permission of your supervisor. Confidential patient information should not be released to nonauthorized individuals. Copies of patient medical records can only be released to parties outside Washington University Medical School/BJH system with written authorization of the patient.

Non-Appointees, by the nature of their positions, may have access to salary information for employees within the Division/Department. Salary information is to be maintained in the highest confidence. This information should never be discussed with individuals who do not have a valid need or right to know the information. Any request as to the release of such information, should be referred and cleared with your supervisor prior to its release.


I agree to maintain any and all “CONFIDENTIAL” information or data that I may come into contact with during the course of my assignment(s) to the highest degree of confidence as outlined above. I agree to protect the confidentiality of the data contained in any computerized system I may use in conducting business for Washington University. I agree that I will not disclose my User Name/Password to any unauthorized personnel. If I have reason to believe that my User Name or Password has become known to an unauthorized user, I will
contact my supervisor immediately and request a new code be assigned as soon as possible. I understand and agree that it is my responsibility to always sign out of the computer system whenever I leave my work area for an extended period of time.

The University’s security policies have been reviewed with me and I agree to comply with all University information system security policies. I understand that if I violate this Confidentiality Agreement, or the University’s information system security policies, I may be subject to disciplinary action in accordance with University policy including termination and possible legal action.