Screener Confidentiality Form

[Insert Logo or Letter Head]
Screener Confidentiality Form 

The issues of confidentiality and ethics are extremely important when taking part in a suicide screen. Each member of the screening team must make the commitment to keep personal student information strictly confidential. The following information should only be shared amongst the screening team. 

• Names of student 

• Medical information shared by the student 

• Details of conversations 

It is our obligation to protect the rights and preserve the self-respect of our students and to preserve the integrity of our district. 

Please consider the following when holding your sessions with students: 

• Please talk to students out of earshot of other people. 

• Either destroy or turn in all documents and notes with student information on it. 

Printed Name:_______________

Signature:_________________________________        Date:_______