MASSACHUSETTS COVID-19 VACCINATION PROGRAM -- Color Application Individual User Agreement
Franklin Regional Council of Governments (the “Commonwealth Site”) has entered into a Massachusetts Vaccination Program Color Application Commonwealth Site User Agreement in order to use certain Vaccine Distribution Technology or VDT Services (the Color  Application)  made  available  by  Massachusetts  Department  of  Public  Health (“MDPH”  or  “the  Department”)  pursuant  to  contract  number  NTF5216U11W21135048 with Color Health for the purpose of facilitating the operation of a vaccination site  for vaccination,  including  but  not  limited  to  scheduling,  record  keeping,  and  billing.    The Commonwealth Site’s use of the Color Application is governed by the Color Application Commonwealth Site User Agreement (the “Site Agreement”).  

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I, the undersigned, understand that as part of my work for the Commonwealth Site, I will be  granted  access  to  the  Color  Application.    I  understand  that  access  to  the  Color Application is provided for the sole purpose of that work.  I understand that the information contained within the Color Application may be confidential.I  recognize  that  the  unauthorized  use  or  disclosure  of  any  confidential  information contained  in  the  Color  Application  may  cause  harm  to  individuals  and  damage vaccination  efforts.  Such  unauthorized  use  is  inconsistent  with  the  terms  of  the  Site Agreement and may be a violation of state and/or federal law. *
TYPE YOUR INITIALS AFTER EACH QUESTION TO CONFIRM YOUR AGREEMENT WITH THE FOLLOWING QUESTIONS.
In order to preserve the confidentiality and integrity of the data contained in the  Color Application, I acknowledge and agree that:
1. I will respect the confidentiality of all confidential information to which I have access  within  the  Color  Application.  I  will  not  disclose  any  confidential information  unless  authorized  to  under  the  Site  Agreement  and I will  not attempt to access confidential information to which I am not entitled. (TYPE INITIALS) *
2. I  will  use  the  Color  Application  solely  for  the  purpose  of  facilitating vaccinations  in  accordance  with  the  Site  Agreement  and  any  applicable guidance, including from MDPH. (TYPE INITIALS) *
3. I will use the Color Application and access confidential information within the  Color  Application  solely  in  accordance  with  the  role  I  have  been assigned by the Commonwealth Site. (TYPE INITIALS) *
4. Any passwords and/or identification codes assigned to me for access to the Color  Application  are  intended  for  my  use  only  in  connection  with  the purposes  set  forth  in  the  Site  Agreement.    I  understand  that  I  will  be accountable  for  all  activities  performed  under  my  assigned  passwords and/or identification codes.  I will not disclose my passwords/identification codes to others and will be responsible for assuring that any employees that I supervise are assigned their own passwords/codes. (TYPE INITIALS) *
5. I understand that my use of the Color Application may be subject to auditing. (TYPE INITIALS) *
6. I will participate in required trainings offered regarding my use of the Color Application  and  will  review  the  written  training  materials  provided.    I  will comply with these and any future modifications to training materials. (TYPE INITIALS) *
7. I  will  immediately  report  to  my  supervisor,  or  if  I  am  the  supervisor,  to MDPH, any misuse of the Color Application, or anything which leads me to suspect that the security of my own passwords has been compromised. (TYPE INITIALS) *
7. I  will  immediately  report  to  my  supervisor,  or  if  I  am  the  supervisor,  to MDPH, any misuse of the Color Application, or anything which leads me to suspect that the security of my own passwords has been compromised. (TYPE INITIALS) *
8. I  will  report  to  my  supervisor,  or  if  I  am  the  supervisor,  to  MDPH,  any inappropriate disclosure of confidential information contained in the Color Application. (TYPE INITIALS) *
9. I will not discuss confidential information contained in the Color Application except  in  the  performance  of  Site  Agreement-related  duties  and  only  if authorized. (TYPE INITIALS) *
10. I understand that infringement of these rules could result in the denial of future authorization of access to the Color Application. (TYPE INITIALS) *
Type your FULL NAME in the next section.
By typing my full name here I confirm that I have read the Site Agreement and agree to abide by the conditions therein. *
Please enter today's date. *
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My role is: *
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My email address (for the purposes of creating a Color user account) is: *
My cell phone number is: *
This form is for the Franklin Regional Council of Governments Commonwealth Site.
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