PIT Confidentiality Form

Central Oregon Continuum of Care

Point in Time Count Volunteer Confidentiality Agreement
As a volunteer with Central Oregon Point in Time Count, (hereafter referred to as the “PIT Count”), I understand my role and responsibilities are a valuable part of the work of the PIT Count, and I agree to carry out my responsibilities to the best of my ability. This is to certify that I, as a volunteer with the PIT Count, understand that any information (written, verbal, or other form) obtained during the performance of my duties must remain confidential.
Volunteer Agreements

Please type your initials under each item indicating that you understand and agree to each. If you do not understand any item, please ask for an explanation and do not initial until you understand and agree.
I agree not to disclose any confidential information acquired during my volunteer service with the PIT Count, to any third party – including media - either during my service with the PIT Count or after my service with the PIT Count has ended. This is in recognition of the difficult situations individuals experiencing homelessness face, and demonstrates respect for those who support them on a day-to-day basis.
Initial*
I agree to refrain from posting photos of survey participants, other volunteers, survey materials and all survey locations. I agree to uphold participant confidentiality in all use of social media during and a1er the count.
Initial*
I understand that all donations/incentives distributed to interviewees as part of the PIT Count are solely for recognizing the contributions of the interviewees.
Initial*
I agree to respect the needs of these individuals by not keeping any donations/incentives for my own personal use, and leaving all left over donations/incentives with the agency I am volunteering at or with my local Point of Contact.
Initial*
Unless authorized in the course of my volunteer duties, I will not make public statements to the media, expressly or implied, on behalf of the PIT Count about any individual I encounter during my volunteer activities.
Initial*
I understand that any unauthorized release or carelessness in the handling of this confidential information is considered a breach of the duty to maintain confidentiality.
Initial*
I understand that any breach of the duty to maintain confidentiality could be grounds for immediate dismissal from this PIT Count and future counts, and/or possible liability in any legal action arising from such a breach.
Initial*
I understand that a breach of confidentiality is warranted only where a survey participant poses immediate and serious harm to themselves or others. I will immediately notify my Point of Contact (POC) if these issues should arise.
Initial*
By signing below, I acknowledge that I have read, fully understand, and accept the responsibilities set above relating to personal, confidential and/or proprietary information.
Signature

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Name

First NameLast Name
Organization/Agency*
Email*
Phone Number*
BendRedmondLa PineSistersMadrasWarm SpringsPrinevilleAny city in Central Oregon
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Central Oregon Continuum of Care

Volunteer Agreements

By signing below, I acknowledge that I have read, fully understand, and accept the responsibilities set above relating to personal, confidential and/or proprietary information.