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Thirty Years of Connecting Communities

Documents and Forms

Confidentiality Forms & Policies

 Client Notice of Rights / Confidentiality Form

This form is used to provide upfront notice to each client about their rights and your practices, including your agency’s information sharing and confidentiality protections and requirements, and their rights regarding the confidentiality of their personal information and communications.

Client Notice of Rights/Confidentiality Form – English Version
Client Notice of Rights/Confidentiality Form – Spanish Version

Confidentiality Policies

General Philosophy & Principles on Confidentiality for Community-Based Domestic Violence/Sexual Assault Advocacy Programs

This piece addresses principles that partners can agree to respect regarding: transparent notice of victim/client rights, differing confidentiality and information sharing obligations, confidentiality walls, policy adherence, confidentiality commitments and duration, law, and technology use. It suggests trainings and policies for specific innovative partnership types.

Model Policy: Confidentiality, Privacy, and VAWA 2005 for Community-Based Domestic Violence/Sexual Assault Advocacy Programs

This model policy has sections addressing: general principles; a written agreement to maintain confidentiality; definitions including what constitutes confidential and personally identifying information; the prohibition to release information to anyone outside the agency (e.g. shelter address, staff and survivor information); protocols for releases of information; and possible exceptions to confidentiality including mandatory reporting. This policy is intended to be signed by all agency/program staff.

Click here to request this template from NNEDV

Template Policy: Confidentiality and Privacy for Co-Located Domestic Violence / Sexual Assault Advocacy Programs and Partners

This technology and confidentiality model policy has sections addressing: common goals and understandings, information that gets collected during any collaboration intake process, assessing interest in services and safety planning, protecting confidentiality while collecting victim information, and, details around managing the confidentiality of information inflow and outflow.

Click here to request this template from the NNEDV

Template Policy: Securing Paper and Electronic Information for Co-Located Domestic Violence/Sexual Assault Advocacy Programs and Partners

This details policies that individual agencies and innovative partnerships should address to secure all electronic, paper and faxed records and information, including computers, electronic networks, and passwords.

Click here to request this template from the NNEDV

Template Policy: Sharing Physical Space for Co-Located Domestic Violence / Sexual Assault Advocacy Programs and Partners

This technology and confidentiality template policy briefly addresses staff roles, office space, and building security for entities that share a building or have physical access to the space occupied by the partnership.

Click here to request this template from the NNEDV

Template Policy: Victim Confidentiality Considerations For Domestic Violence and Sexual Assault Programs When Responding to Rare or Emergency Situations

A wide range of situations can arise for programs providing services to victims of domestic violence, dating violence, sexual assault, or stalking. Given the complex and critical safety issues faced by victims, programs should have policies to address victim safety and confidentiality in unusual or emergency circumstances. Examples of special situations that might arise include: medical and other emergencies; instances where a victim/client (or the victim’s child) commits a crime while accessing or using services; and, situations where a victim brings civil or criminal claims against another client or the agency. Programs/agencies should practice best confidentiality and safety practices in each special circumstance that arises. This piece highlights what programs need to know about confidentiality and discusses how programs can respond in: (A) medical or emergency situations; (B) crime or other claim against a victim advocacy program; and (C) a crime or other claim by one survivor against another survivor using program services.

General Reference

Training Bulletin: Advocates, Routine Notification, and HIPAAA follow-up addressing some common questions and concerns regarding HIPPA (Health Insurance Portability and Accountability Act).

Training Bulletin: Advocates, Routine Notification, and HIPAA

Medical

Colorado Hospital Payment Assistance: As of August 8th, 2012, your local hospital is required to offer you information about its charity care and hospital discount programs. These flyers provide information on Colorado Hospital Payment Assistance Programs for Patients.

Information on Colorado Hospital Payment Assistance Program for Patients – English Version
Information on Colorado Hospital Payment Assistance Program for Patients – Spanish Version

Medical Forensic Exams In Colorado

Fact sheet on the access and methods of payment for Medical Forensic Exams in Colorado

Medical Forensic Exams Fact Sheet

Colorado Consent From for Drug-Facilitated Sexual Assault Screening

This form is for distribution by medical professionals.

Colorado Consent Form for Drug-Facilitated Sexual Assault Screening

Information Sheet for Patients on Obtaining Test Results Following a Drug Facilitated Sexual Assault Screening.

This information sheet is for patients who wish to obtain the test results of their Drug-Facilitated Sexual Assault Screening.
 Non Reporting: How to Obtain Drug Test Results

 

Multi-Agency Partnerships

Equipment Ownership Agreement Form

This adaptable agreement form was created for agencies in colocated partnerships although it can be useful in other agency settings as well. It provides agencies in colocated partnerships with an easy way to clearly stipulate who has ownership of any hard drive or devices that holds personally identifiable information. Due to the nature of harddrive memory, certain OVW-funded community based organizations need to maintain ownership of such harddrives and devices in order to comply with their VAWA 2005 confidentiality obligations.

Equipment Ownership Agreement Form

Template Memorandum of Understanding: Partnership Agreement for Community Collaborations

This Memorandum of Understanding (MOU) was created for non-profit victim service agencies in co-located partnerships. This MOU addresses policies to govern the partnership between non-profit organizations and programs that provide services to survivors of domestic and dating violence, sexual assault, and stalking and other community agencies. It details the individual partner’s roles and responsibilities, as well as information sharing and confidentiality obligations for the domestic/dating violence and/or sexual assault agency, law enforcement, prosecutor, court partner, medical partner, faith-based and community organizations, and a confidentiality monitor. All partners must sign to acknowledge the agreement.

Non-profit victim service agencies that provide services to survivors of domestic violence, dating violence, sexual assault and stalking in innovative partnerships are encouraged to use this adaptable MOU agreement. Agencies may change wording to match organizational language or to reflect the language that the partnership prefers (e.g. client, victim, survivor, program participant).

Click here to request this form from the NNEDV

Visitor Confidentiality Agreement

The purpose of this Template Visitor Confidentiality Agreement is to ensure that each visitor to a shelter, rape crisis center, transitional housing, family justice center or other victim service agency understands their confidentiality obligations and respects the privacy of clients, staff, and volunteers of the agency or colocated partnership. This can be used to address visits to or meetings with clients, staff, or volunteers whenever there are confidentiality obligations.

Visitor Confidentiality Agreement

Release of Information

 Client Limited Release of Information Form

This form is used to help a client assess risks and benefits of having an agency release some of her/his confidential information to another individual/agency. The form enables the client to choose what information an agency may share, how it is shared, with whom, and for how long.

Client Limited Release of Information Form – English Version
Client Limited Release of Information Form – Spanish Version

Sexual Assault Response Team (SART)

NSVRC Acronym List

List of acronyms from the National Sexual Violence Resource Center.

NSVRC Acronym List

SART Readiness Assessment

This brief assessment tool provides communities with the opportunity to explore community readiness for sexual assault response team development regarding perceptions, resources and services.

NSVRC SART Readiness Assessment

Planning For a SART

This worksheet helps you asses your readiness for a SART.

Planning for a SART Worksheet

Team Building

Here is a resource to help build your response team.  This worksheet helps you build your SART by asking you questions that need to be addressed.

Team Building Worksheet

SART Development: A Guide for victim service providers

The focus of this technical assistance guide is to help sexual assault service providers build, expand, formalize, and maintain strong interagency responses to sexual violence. It includes a brief overview followed by Practice Tips, Ways to Build SART Excellence, and Key Resources.

NSVRC Sexual Assault Response Team Development

Critical Elements and Agency Leadership

The purpose of this inventory is to encourage the multidisciplinary sexual assault response team to discuss and review which services are and are not offered, by which agency(s), and if duplication/overlap of services is a potential problems.

Critical Elements and Agency Leadership

 Existing Community Services

The purpose of this form is to help you identify the services that you have in your community.

Existing Community Services

Case Review: Confidentiality Rules and Agreements

This is a sample confidentiality rules and agreement for case reviews.

Case Review: Confidentiality Rules and Agreements

Tips for Conducting Focus Groups

These are some tips for teams who are conducting focus groups.

Tips for Conducting Focus Groups

SAMPLE — Needs Assessment Survey

This is a sample of a needs assessment survey.

Needs Assessment Survey

Florida SART Toolkit

The purpose of this toolkit is to provide users with a step by step guide for creating and maintaining a Sexual Assault Response Team (SART)

Florida SART Toolkit

SART Manual in Tribal Communities

A resource guide for the development of a sexual assault response team (SART) in tribal communities.

SART Manual in Tribal Communities

SART Resource List

A list of resources compiled by the West Virginia Foundation for Rape information and Services.

SART Resource List

National Sexual Assault Response Team Survey Report 2009

This report summarizes the information gathered by the National Sexual Violence Resource Center
(NSVRC) via a web-based survey regarding how local, state, territory and tribal communities have
developed Sexual Assault Response Teams (SARTs). The survey is a follow-up to the national needs
assessment conducted in 2005 by NSVRC. The information from the current survey will help NSVRC obtain an updated picture of SARTs nationwide.

NSVRC Reports National SART Survey 2009