Get Individual User Agreement And Confidentiality Statement

Completing the Individual User Agreement And Confidentiality Statement is essential for users seeking access to the I-CARE Registry. This guide provides clear and concise steps to help you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to retrieve the form and have it displayed in your browser.
2. Read through the document carefully to understand the responsibilities and conditions regarding access to the I-CARE system.
3. In the designated area, print your full name legibly as an employee on the line labeled 'Employee Name (please print legibly)'.
4. Sign your name in the 'Employee Signature' field indicating your agreement with the confidentiality statement.
5. Enter the date of your signature in the 'Date' field provided.
6. Provide the facility name and location, including the street address, city, state, and ZIP code, in the appropriate area.
7. Fill in the phone number, including the area code, in the designated field.
8. Input your individual email address in the space provided; ensure that it is not a group or multi-user email.
9. Select the level of access required (View Only, Full Access, or Inventory Lot Management) by marking the appropriate box.
10. The site manager or supervisor must sign the form in the 'Site Manager or Supervisor Signature' field to authorize access.
11. Review the completed form for any errors or missing information before saving your changes.
12. Once completed, you may choose to download, print, or share the form as required, and return page one via fax, mail, or email as instructed.

Complete your Individual User Agreement And Confidentiality Statement online today!