DCOM Confidentiality Agreement

____________________________________ District District Committee on Ordained Ministry (DCOM) Confidentiality Agreement This confidentiality agreement (the “Agreement”) is between the _______________________________ District Committee on Ordained Ministry (DCOM), of the Holston Conference, and an “Individual” serving in the capacity as a member of that Committee either via direct appointment by the District Superintendent and/or District Leadership Team. *First Name

*Last Name

*Preferred Name

*Phone

*Email

Term: This Agreement applies to discussions between the individual and the District Committee on Ordained Ministry related to the Individual’s position as a member of the District Committee on Ordained Ministry, this agreement is in effect in perpetuity in regards to all information learned as a member of the District Committee on Ordained Ministry.

Acknowledgment: The Individual understands and acknowledges that in his or her position as a member of the District Committee on Ordained Ministry, that the Individual will receive confidential information pertaining to the activities, operation and business of the District Committee on Ordained Ministry and or financial, psychological, medical and other personal information of candidates and local pastors that come before the District Committee on Ordained Ministry. The Individual further acknowledges that any unauthorized release or carelessness in the handling of such confidential information may be prejudicial and/or injurious to the District Committee on Ordained Ministry and/or candidates and local pastors that might come before this Committee.

Confidentiality: The Individual agrees to: *Not disclose or discuss Confidential Information with others not authorized to receive such information-(other members of this Committee, Director of Clergy Services, and the staff related to the Director of Clergy Services); Yes No *Use reasonable means to protect and prevent the disclosure of Confidential Information whether oral or written; Yes No *Use the confidential information only in connection with the District Committee on Ordained Ministry and the Individual’s time on that Committee.

Yes No

Remedy: If an individual violates this Agreement, the District Committee on Ordained Ministry may ask the District Superintendent to remove and replace the Individual immediately from their position on the District Committee on Ordained Ministry. Such violation may result in the Individual from being able to serve in other positions that allow access to confidential information.

Signature: My signature demonstrates my agreement to hold confidential all information to which I am privy in my role as a member of this District Committee on Ordained Ministry.

Print your full name below. By printing your name and signing in the area below you are verifying your name and date of this signature. *Print Full Name

*Signature of Full Name

*Date

Upon completion of this form please return it to your DCOM Chair.