WITH HIV-REIATED
ILLNESS EXHIBIT
The University of the State of New York Education Department
Approved by:
New York State Department of Health
Authorization for Release of Confidential HIV*
Authorization for Release of Confidential HIV*
Related Information to the Superintendent of
Related Information to the Superintendent of
Schools and the Board of Education
Schools and the Board of Education
OC-I (6/89)
Confidential HIV Related Information means any information indicating that a person had an HIV related test, or has HIV infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
Under New York State Law, except for certain people, confidential HIV related information can only be given to persons you allow to ave
it
by signing this form. You may ask for a list of people who can be given confidential HIV related information even without this form.
If you sign this form, HIV related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you experience discrimination because of the release of HIV related information, you may contact the New York State Division of Human Rights at (212) 870-9624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.
| NAME OF PERSON WHOSE HIV RELATED INFORMATION WILL BE RELEASED
|
| NAME AND ADDRESS OF PERSON SIGNING THIS FORM (IF OTHER THAN ABOVE)
|
| |
| RELATIONSHIP TO PERSON WHOSE HIV INFORMATION WILL BE RELEASED
|
| NAME OF SCHOOL DISTRICT
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| Name and addresses of the Superintendent of Schools and individual mem hers of the Board of Education (Board of Trustees,) of the above named school district who will be given HIV related
|
| information
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| SUPERINTENDENTS NAME
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| STREET CITY STATE ZIP CODE
|
| NAME
|
| STREET CITY STATE ZIP CODE
|
CONFLICT OF INTEREST
CONFLICT OF INTEREST
The Board of Education is committed to avoiding any Situation in which the existence of simultaneous, conflicting interests in any officer or employee may call into question the integrity of the management or operation of the school district. Therefore:
No person employed by the district shall hire, supervise, evaluate, promote, review or discipline any other employee who is a member of the same family. In the event that marriage, promotion, or reorganization results in a situation not in compliance with this policy, reassignment or transfer will be effected, in accordance with the applicable provisions of any collective bargaining agreement, to correct the situation.
No person employed by the district shall negotiate or execute any contract on behalf of the district for the purchase, sale or lease of real or personal property, services of any nature, nor for insurance without first having determined the common price for such property, services or insurance, or requesting bids from all potential providers of such property, services or insurance.
No person employed by the district shall allow any matter, concern or interest, personal, financial or otherwise, to influence or interfere with the performance of his or her duties. Should such a matter, concern or interest arise, the employee shall bring the matter to the attention of his or her supervisor to seek ways to reduce or eliminate the influence or interference.
No person employed by the district shall hold a compensated position outside of his/her school district position which interferes with the proper execution of regularly assigned school district duties.
The Board affirms its commitment to adhere scrupulously to all applicable provisions of law regarding material conflicts of interest.
Knowing or willful violation of this policy by any employee may result in disciplinary action up to and including dismissal.
Any officer, employee or member of the public noting or suspecting a violation of this policy is encouraged to bring the matter, either in confidence or in public, to the Board or the Superintendent of Schools.
Cross-ref: 2170, Board Member Conflict of Interest
Ref: Education Law
§§
410, 3016
General Municipal Law Art. 18,
§§
801-813
Labor Law §201-d
Dykeman v. Symonds, 54 AD2d 159 (4th Dep’t 1976)