Statement of Confidentiality & Disclosure I _____________________________________________________________, the undersigned, an employee of the State of Wyoming (Department of Family Services) I understand certain material, which I may handle or create during the course of my employment, may be covered by confidentiality requirements. I further acknowledge that in the performance of my duties, I may acquire or have access to "personal data" and become a "holder" of such personal data or other information deemed confidential under state or federal law, regulation, or common practice. I shall comply with state and federal laws and regulations relating to confidentiality and shall not divulge any personal information or data to ANYONE other than officers and employees of the Department of Family Services who are permitted access to such information by federal or state laws, rules, regulations, or Memorandums of Understanding (MOU) in order to perform their officially assigned job functions. I understand that certain material, which I may handle or create during the course of my employment, may personally affect me, a member of my immediate family or extended family or my significant other(s). I acknowledge that access to such personal data could cause temptation and conflict between my personal and professional responsibilities. To avoid any possibility of difficulty, I shall immediately cease all activity on a case or work task and immediately advise my superior of any conflict that may result in my inability to objectively perform my professional responsibilities or that has even the appearance of impropriety. I further understand failure to disclose and/or notify my immediate supervisor of the conflict and/or failure to immediately terminate activity on the case, as provided above, will result in appropriate disciplinary action and possible prosecution. I understand that state policy requires that all passwords, ID numbers and other procedures related to the legitimate access of data are personal to the employee to whom access is authorized and cannot be shared with anyone. I will comply with this statement and I am aware that a violation of this oath will result in appropriate disciplinary action and possible prosecution. The completion and submission of this form constitutes your signature. Please complete within thirty (30) working days from your first day on the job. _________________________________________ EMPLOYEE SIGNATURE and DATE __________________________________________ EMPLOYEE NAME (TYPE OR PRINT)