Effective upon submission of this Consent for Disclosure of Personally Identifiable Information (“Consent”), I hereby authorize Clinical Placement Consortium #1, North Puget Sound Clinical Placement Consortium, and Inland Northwest Clinical Placements Consortia (collectively referred to as “CPNW”) to disclose and provide my personally identifiable information as provided in this Consent.
The personally identifiable information subject to this Consent (“PII”) includes any and all personally identifiable information I have provided to CPNW. My personally identifiable information may include my contact, identification, and demographic information; my educational affiliations, including but not limited to the educational institutions’ verification of such affiliations; copies of documentation relating to my immunizations; history of infectious diseases; titer levels; background checks; personal identity, including but not limited to social security number; nursing skills check-off lists; results of health training modules on such topics as compliance requirements, patient confidentiality, HIV/AIDS, and universal infectious disease precautions; and other records and documentation which may include other personally identifiable, sensitive information that I have provided to CPNW.
I authorize CPNW to disclose this personally identifiable information upon request to:
I understand I have the right to revoke this authorization by electronic request to CPNW at firstname.lastname@example.org. I understand the revocation will not apply to information that has already been released in response to this authorization.
I further understand that once the PII I have authorized to be disclosed reaches the recipient, that person or organization may use or re-disclose it, and that CPNW has no control over or responsibility for such use or disclosure.
By completing the following information and submitting this form to CPNW, I acknowledge that I have been informed of and consent to the terms and conditions of this Consent, and that CPNW will rely upon this Consent in disclosing my PII.