Templates for Agencies Working with Survivors
1. Notice of Rights / Confidentiality Form for Advocacy Organizations
This form is used to provide upfront notice to each person receiving services about their rights and your policies, including your agency's information sharing practices, confidentiality requirements, and the their rights regarding the confidentiality of their personal information and communications.
Download this template in English
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2. Limited Release of Information Form for Advocacy Organizations
This form is used to help a survivor assess the risks and benefits of having an agency release some of her/his confidential information to another individual/agency. This form enables the client to choose what information an agency may share, how it is shared, with whom, and for how long.
3. Model Intake Form
For many programs, the intake process is one of the beginning steps in establishing a trusting relationship with a survivor and assessing their needs and requests for services. It’s important that this process is nonintrusive and avoids the collection of unnecessary personally identifying information. This template uses best practices to guide this process in the most helpful way possible for the survivor.
4. Documentation Retention Policy / Procedures
This template policy addresses programs’ procedures and practices around document retention and destruction. Having these policies in place helps programs to ensure that their entire data management process, not just the collection aspect, is prioritizing confidentiality.
5. Visitor Confidentiality Agreement:
The purpose of this template is to ensure that each visitor to a confidential shelter, rape crisis center, transitional housing program, or other victim service agency understands his or her confidentiality obligations and respects the privacy of survivors, staff, and volunteers of the agency or co-located partnership.
6. 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 constitute 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.
Templates for Community Collaborations
1. General Philosophy & Principles on Confidentiality for Community-Based Domestic Violence/Sexual Assault Advocacy Programs
This piece addresses principles that partnering agencies can agree to respect: transparent notice of victim/client rights, differing confidentiality and information sharing obligations, confidentiality walls, policy adherence, confidentiality commitments and duration, laws, and technology use. It suggests trainings & policies for specific innovative partnership types.
3. Confidentiality and Privacy for Community Collaborations with Domestic Violence/Sexual Assault Advocacy Programs and Partners
This template addresses service providers’ understandings and responsibilities, victims' rights, and the limited sharing of client/victim information with collaboration partners and provides guidelines for addressing system issues through the community collaboration.
4. Memorandum of Understanding (MOU): Partnership Agreement for Community Collaborations
This template Memorandum of Understanding (MOU) addresses policies to govern a partnership. It details individual partner roles and responsibilities, including information sharing and confidentiality obligations for a domestic violence/sexual assault agency, law enforcement, prosecutor, court partner, medical partner, faith-based and community organization, and a confidentiality monitor. All partners sign to acknowledge the agreement.
Templates for Co-Located Partnerships
1. Confidentiality and Privacy for Co-Located Domestic Violence/Sexual Assault Advocacy Programs and Partners
This 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.
2. Equipment Ownership Agreement Form for Partnerships
This form is to ensure that all agencies in a co-located partnership with policies or legal obligations to maintain the confidentiality of client records and data have clear agreements stipulating ownership of their paper files, hard drives, or other devices that contain confidential data.
3. Sharing Physical Space for Co-Located Domestic Violence/Sexual Assault Advocacy Programs and Partners
This 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.
4. Securing Paper and Electronic Information for Co-Located Domestic Violence/Sexual Assault Advocacy Programs and Partners
This template 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.