Attachment 10 Confidentiality Pledge

Attachment 10:
Confidentiality Pledge

Screening, Brief Intervention, Referral and Treatment Project

Assurance of Confidentiality

RTI International assures each respondent that the confidentiality of responses to this information request will be maintained by RTI and that no information obtained in the course of this activity will be disclosed in a manner in which the particular individual supplying the information or described in it is identifiable, unless such individual has consented to such disclosure, to anyone other than authorized project staff at RTI International.

Agreement

I have carefully read and I understand the Assurance of Confidentiality that pertains to the confidential nature of all data to be handled in regard to this project. As an employee of RTI International, I pledge that I will not disclose any confidential information obtained under the terms of this contract to anyone other than authorized project staff at RTI International.

I further understand and agree to comply with the following confidentiality provisions:

1. Any materials that would permit the identification of survey participants are to be treated as confidential. These include both hardcopy records and electronic files.

2. Confidential records must be kept in a locked container or room when not in use.

3. When confidential records are in use in a room, admittance to the room is to be limited to persons who have signed the project Confidentiality Pledge.

4. Keys and combinations to locked rooms and containers must be protected from unauthorized access.

5. Information obtained from the data collected or used under this contract may not be released to unauthorized persons.

6. No data, tabulations, or analyses obtained under this contract may be released or used without prior written approval of the CSAT.

7. Any breach of confidentiality must be reported immediately to the RTI project director, Dr. Jeremy Bray, at 1-800-###-####, extension ####.

Name (Print)
Signature		Date

Disposition: Original to Project File (Arnie Aldridge); Copy to Employee

Revised: January 5, 2006