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Date
As a condition of doing research concerning persons with developmental disabilities who have received services from ______________________________ (fill in the facility, agency or person), I, ____________________, agree to obtain the prior informed consent of such persons who have received services to the maximum degree possible as determined by the appropriate institutional review board or boards for protection of human subjects reviewing my research, or such person's parents, guardian, or conservator, and I further agree not to divulge any information obtained in the course of such research to unauthorized persons and not to publish or otherwise make public any information regarding persons who have received services such that the person who received services is identifiable.
I recognize that the unauthorized release of confidential information may make me subject to a civil action under provisions of the Welfare and Institutions Code.
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Signed
Cal. Code Regs. Tit. 17, § 50421
Note: Authority cited: Sections 4514(e) and 5328(e), Welfare and Institutions Code. Reference: Sections 4514(e) and 5328(e), Welfare and Institutions Code.