Cost Reimbursable Research Request--Application Reporting

OMB Control No 0960-XXXX

Expiration Date: XX/XX/XXXX

Confidentiality Agreement

Purpose: This form is for all users of SSA sensitive data to certify that they understand SSA’s security, confidentiality and ethics requirements.

I understand the SSA security, confidentiality and ethics requirements and agree that:

0. I will comply with all the confidentiality and legal requirements as stated in the contract, Memorandum of Agreement (MOA), or other documentation when using SSA sensitive data.

2. I will follow all security and safeguard provisions as described in the SSA Data Protection Plan when using SSA sensitive data.

2. I agree not to construct and maintain, for a period of time longer than stated in the contract, MOA, or other documentation, any file containing SSA sensitive data unless explicitly agreed to by SSA in writing.

2. I agree not to link any other data to the SSA sensitive data described in the contract, MOA, or other documentation or any derived dataset (s) unless explicitly agreed to by SSA in writing.

2. I will use proprietary software, i.e. computer software that complies with Federal copyright laws and licensing agreements.

2. I agree to keep confidential any third-party proprietary information that may be entrusted to me as part of the contract, MOA, or other documentation.

2. I will not release or disclose any information subject to the Privacy Act of 1974, section 6103 of the Internal Revenue Code, SSA Regulation 1 (20 C.F.R. Part 401), and section 1106 of the Social Security Act to any unauthorized person.

2. I understand that I may be subject to a site inspection (s) by SSA to ensure that adequate security safeguards, controls and confidentiality are maintained as specified in the SSA data protection plan and in the contract, MOA, or other documentation.

2. I understand that disclosure of any information to parties not authorized by SSA may lead to civil or criminal prosecution under Federal law and/or regulations.

2. I understand that I can be subject to a personnel security and suitability background investigation.

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User Date

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 4 hours to read the instructions, gather the facts, and answer the questions.

If you have comments on our time estimate please send them to: SSA, 6400 Security Blvd. Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.

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