<p> Pregnancy Associated Mortality Review Confidentiality Agreement</p><p>By signing this Confidentiality Agreement, each individual (hereinafter “participant”) agrees to participate on the State-wide Pregnancy-Associated Mortality Review (PAMR) team and to abide by the confidentiality requirements set forth herein. </p><p> In accordance with section 3701.14 of the Ohio Revised Code and under a grant funded by the United States Department of Health and Human Services, Agency for Healthcare Research and Quality, OSU and ODH are partnering to carry out a study of pregnancy related deaths in Ohio.  As a participant on PAMR, you will receive de-identified case summaries including clinical data for pregnancy related deaths in Ohio. As a participant on the PAMR team, you will be asked to prepare individual case recommendations from the clinical data provided.  Best efforts will be made by OSU and ODH to provide de-identified data. Nevertheless, if data is provided that could be considered protected health information, by signing this Agreement participant agrees to and is hereby bound by section 3701.17 of the Ohio Revised Code and HIPAA as applicable.  The information provided during the PAMR meetings and reviewed by participant is the sole property of OSU and ODH jointly and is intended for exclusive use to carry out a study of pregnancy associated deaths in Ohio and develop recommendations to prevent future pregnancy associated deaths.  Although OSU and ODH will take reasonable measures to assure the data summaries and clinical data is de-indentified, participant assumes full responsibility for any use or dissemination of any information that is provided as part of the PAMR team review and may be subject to RC 3701.17 confidentiality provisions. Any unauthorized use of confidential information in violation of this Agreement may result removal from the PAMR team and may subject participant to legal action.  Each participant agrees at all times to utilize best practices in safeguarding and maintaining the confidentiality of PAMR information.  The participant may not designate another individual to participate on participant’s behalf without first obtaining approval from OSU and ODH. Any one designated by participant with approval from OSU and ODH must first sign this agreement before participating. </p><p>By signing below, I agree to the terms of this Confidentiality Agreement: Print Participant’s Name Participant’s Signature Date</p>