Adopted: January 1978
Revised: May 2018
Download 505.2.3P Somali - Prior Consent to Release Private Data To or From an Outside Agency/Person
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Waalidka / mas'uulka: Foomkan oggolaanayaa in macluumaad ku saabsan ilmahaaga in la isweydaarsan karo. Fadlan saxiix kuna soo celi dugsiga. |
Magaca ardayga oo buuxa____________________________________ Taariikhda dhalashada __ __ -__ __-__ __ Dugsiga_____________________________Fasalka_______ |
Magaca waalidka/mas'uulka
Adreeska waalidka / wakiilada
Waxaan fasaxayaa
Magaca dugsiga degmada iyo / ama nambarka iyo qofka mas'uul ka ah
adreeska
magaalada gobolka sib koodhka
lambarka taleefanka email lambar fax ah
(Calaame sida hadba loogu baahdo) ______ inay warbixintan siin karaan: ______ Macluumaad laga heli karo:
magaca jagada
hay'adda
adreeska
magaalada gobolka sib koodhka
lambarka taleefanka email lambar fax ah
The purpose for the request
Diiwaanada dugsiga ayuu eegi karaa waalidka / mas'uulka, ama ardayga 18 jir ah ama ka weyn. Koobi ka mid ah foomkan oggolaanshaha haddii la codsado ayaa la bixin doonaa. Fadlan siidaa kuwa soo socda:
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__ Natiijooyinka baaritaanka iyo macluumaadka kale ee ku jira buugga tusaha faylka wadareed __ Xadgudub ee Kiimikada iyo warbixin ku tiirsanaanta __ Diiwaanka Caafimaadka __ Macallinka, la-taliyaha, indhaynta shaqaalaha __ Diiwaanada daraasadda Caruurta / waxbarashada gaarka ah (oo ay ku jiraan adeegyada la xiriira)
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__ Wararka shaqada bulshada __ Wararka dhimirka __ Warbixinta Caafimaadka (oo ay ku jiraan adeegyada la xiriira) __ Wararka nafsaaniga __ Kale (tilmaam)___________________ __ Kale (tilmaam)___________________ |
Waxaan fahamsanahay ansixintan ka bilaabanayo maalintii aan saxiixin. Waxaa egyahay
(Bisha, maalinta, sanadka)
ama wax ka badan hal sanno laga bilaabo taariikhda aan saxiixiisa. Waxaan sidoo kale fahamsanahay in aan ka beddeli karo ogolaashadaan waqti walba anigoo ogaysiinaya maamulaha dugsiga ama xubin ka tirsan shaqaalaha kor lagu qorey. Waxaa laga yaabaa in aan diido in aan saxiixo ansixintan iyo mana saamayn doonto awoodda ilmahayga ay u helaan adeegyada waxbarashada. Waxaan fahamsanahay in xaq u leeyahay koobi ka mid oggolaanshaha. Waxaan fahamsanahay in sharciyada ah in ay ilaaliyaan macluumaadka la shaaciin karta iney u oggolaadaan ama aad u baahan dib-u-bixinta macluumaadka, laakiin kaliya sida sharciga ogol yahay.
BAYAANKA HIPAA : Haddii foomka ogolaanshaha ogol yahay in la sii daayo "macluumaad kaaga caafimaadka ee badbaadsan" (PHI) sida lagu qeexay Caymiska Caafimaadka Qaadashada iyo sharciga (HIPAA), Waxaan fahamsanahay in siidaynta dib ee PHI adeeg helaha mar dambe la ilaaliyaa laga yaabaa HIPAA. Daaweynta, bixinta, diiwaan gelinta ama xaq u yeelashada ee manfacyada ka socda qorshe caafimaad ama bixiye daryeel caafimaad waxaa laga yaabaa in in aan lagu qaadanin xaaladdii helitaanka ogolaanshaha.
Saxiixa waalidka / mas'uulka / ardayga 18 jir ama ka weyn Taariikhda
Koobi sax ah sida asalka ah.
Koobi: __ Faylka Daraasadda Caruurta (haddii mid ka mid ah jiro) __ faylka Iskujirka __ Kuwo kale