CASA Advocate Confidentiality Statement

Name*
First Last
Email*
Your Supervisors Email*
Docket Number*
Case Name*
Date of Appointment*
MM slash DD slash YYYY
Confidentiality Oath Signature*

All information I receive will be held in the strictest confidence. When my case is closed, I will return any and all information I obtained during the life of the case to my CASA Advocate Supervisor. If for any reason I can no longer fulfill my responsibilities as the Guardian Ad Litem for the case, I will immediately return any and all information I obtained during the case to my Advocate Supervisor.
Consent*
I agree to the use of an Electronic signature
By electronically signing this agreement, I hereby accept appointment as volunteer court appointed special advocate in the above entitled matter.

I have access to the case records through the CASA of Galveston Optima database system and further understand that I will receive additional case record information, both written and verbal as it becomes available.

I understand that we have sworn to maintain confidentiality of all information that we receive.

I will maintain confidentiality of these case records by:

· Keeping all written records in a secure place while in my possession,

· Not discussing the case with anyone other than parties to the lawsuit and my CASA supervisory staff,

· Following all CASA of Galveston County procedures regarding which records I may keep in my possession and which must remain in the CASA office,

· Returning any written case records to the CASA office within 10 days, either when my case closes, or at such time I resign from the case.

If at any time I feel unable to carry out the duties and obligations assigned, I will immediately consult with the Executive Director.

I have been informed of the Texas Human Resources Code (40.005) which provides that, a person who is authorized to receive confidential information shall maintain its confidentiality and shall prevent disclosure of the information to a person who is not authorized to receive the information. It is a Class A misdemeanor to disclose, without authorization, confidential information contained in the Texas Department of Protective and Regulatory Services records, papers, files, or communications.
Date Signed*
MM slash DD slash YYYY

CASA of Galveston County

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