REQUEST FOR RELEASE OF INFORMATION/RECORDS Permission to Observe

It is understood the records or information so provided will be maintained with all due safeguards as provided by the laws of “privacy and rights.” The purpose of this release of information and records is to provide assistance and needed information to those individuals who may be seeking employment or maintaining current employment for the above-named individual. Information gathered may also be used in data collection for on- going research purposes and in consideration of the business needs of CCHMC. No identifying information shall be shared with others outside of the research entity. This release of information shall be in effect one year from date of signature.