D-1676 Self-Assessment

OMB No. 0607-0795
FORM D-1676
(6-12-2007)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

ENTITY ID

U.S. CENSUS BUREAU

SELF-ASSESSMENT CHECKLIST FOR THE CONFIDENTIALITY
AND SECURITY GUIDELINES
LOCAL UPDATE OF CENSUS ADDRESSES (LUCA) PROGRAM
2010 Decennial Census

Instructions
Please review the Confidentiality and Security Guidelines then check the appropriate response on this
form. If you select LUCA Participation Option 1 or Option 2, sign and return this form together with
your completed 2010 Decennial Census LUCA Registration form, Participation Option/Product
Preference form, and signed Confidentiality Agreement form in the enclosed, postage-paid envelope.
Each LUCA liaison is responsible for protecting and safeguarding the confidential Census Bureau
materials covered by Title 13, United States Code (U.S.C.). This includes any list or file that shows
individual Census Bureau addresses and any map that shows structure points (Structure points will be
displayed on the address list and maps, where applicable, for the Feedback phase of the program) for
dwellings. The liaison must restrict access to the Census Bureau’s address information to only those
individuals who have signed the Confidentiality Agreement. All individuals directly involved in
reviewing the materials for the 2010 Decennial Census LUCA Program and anyone
with access to Title 13 materials must sign the Confidentiality Agreement making a
permanent commitment to protect the confidentiality of Title 13 information.
You must be at least 18 years of age to sign the Confidentiality Agreement.

Protecting Census Bureau Address Information and Maps
Keep all Census Bureau address information and maps showing structure location points (structure points
provided for Feedback phase only) in a locked-room during nonwork hours. During work hours, do not
leave a room unattended where Census Bureau address information and maps are being reviewed.
Additionally, do not leave Census Bureau address information and maps unattended at your desk.
Operating systems, programs, applications, and data related to the review of Census Bureau addresses
must be accessible only to LUCA program liaisons, reviewers and anyone with access to Title 13 materials.
The automated data processing (ADP) system must restrict the read, write, delete, and execute functions
applicable to the Census Bureau’s addresses. If Census Bureau address information is placed on a shared
computer system, create electronic security profiles to allow access only to LUCA Program liaisons,
reviewers, and anyone with access to Title 13 materials. Lock all rooms with computers that contain
Census Bureau address information and all associated media during nonwork hours.
Mark (X) the appropriate
response.
1. Will you store Title 13 materials including the paper address list, CD-ROM/DVD
containing the address list, and/or paper or digital maps containing structure points
(structure points provided for Feedback phase only) in a secure location?
2. If staff members, other than those who signed the Confidentiality Agreement, have
access to the offices, cabinets, etc. where the Census Bureau’s address list and/or
maps with structure points (structure points provided for Feedback phase only) are
stored, will you secure the Title 13 materials (both paper and electronic) to prevent
unauthorized staff from accessing these materials?
3. If Census Bureau Title 13 address information is placed on a shared computer
system, will you construct electronic security profiles to allow only those who
signed the Confidentiality Agreement access to the Census Bureau’s address
information?
4. Will you ensure that your ADP system restricts the read, write, delete, and execute
functions applicable to the Census Bureau’s Title 13 address list file only to those
who signed the Confidentiality Agreement?

1
2

1
2

1
2

1
2

5. Will you assign an encrypted, unique user-ID and password for each LUCA
Program liaison, reviewer, and anyone with access to Title 13 materials?

1

6. Will you keep Title 13 data separate from your other data?
(Title 13 data cannot be backed-up, mixed with, or stored with other data.)

1

USCENSUSBUREAU

2

2

Yes
No

Yes
No

Yes
No
Yes
No
Yes
No
Yes
No

On-site visits
To ensure that participating governments or organizations are maintaining adequate
security safeguards, the Census Bureau may make on-site visits to review your
organization’s security procedures. The Census Bureau will strive not to disrupt your
office’s operations.
Do you understand that the Census Bureau may conduct on-site visits to your office to
inspect your security measures regarding the Census Bureau’s Title 13 materials?

Mark (X) the appropriate
response.
1
2

Yes
No

Environmental or Natural Disasters
Do you have a plan to keep Title 13 materials secure in the event of an actual
environmental or natural disaster (fire, tornado)?

1
2

Yes
No

Return or Destruction of Confidential Census Materials
Once the LUCA Program is over (at the conclusion of the appeals process), the
LUCA liaison must return or destroy all remaining Title 13 materials according to the
Census Bureau’s specific guidelines for returning or destroying confidential material.
The Census Bureau requires that the liaison verify that the participating government
has returned or destroyed all Title 13 Census Bureau address information by signing
and returning the "Return or Destruction of Title 13, U.S.C. Materials" form to the
Census Bureau.
1. Will you clear all magnetic media (tapes, disks, hard drives) containing
Census Bureau Title 13 address information before reuse?
2. Will you destroy all paper and electronic Census Bureau Title 13 address lists and
maps containing structure location points (Feedback phase only) through approved
destruction methods as outlined in the Confidentiality and Security Guidelines or
return these Title 13 materials to your Census Bureau Regional Office?

Mark (X) the appropriate
response.
1
2

1
2

Yes
No

Yes
No

LUCA LIAISON INFORMATION
If your government can meet the above requirements, the LUCA liaison must print and
sign his/her name, job title, telephone number, and enter the date below.
Name of LUCA Liaison – Please print

Signature of LUCA Liaison

Date
Month

Day

Year

Title

Telephone
Area code

Number

–

Page 2

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FORM D-1676 (6-12-2007)