Non-Disclosure Form

Confidentiality Pledge and Non-Disclosure Statement

I, ______________________________, in my role as an employee of Aspen of DC, working as a Field Interviewer for the FY 2010 Quality Control for Rental Assistance Subsidy Determinations Study, HUD/ICF Macro contract GS-23F-9777H (Task Order #: CHI-T0001; C-CHI-01026), understand and agree to comply with the following:

• Confidentiality of Data. All information I obtain, from either formal interviews or in casual observation or conversation, will be treated as confidential and not discussed with any parties not authorized to have access to such data, including (but not limited to) project/PHA staff, other households I may contact, and HUD staff.

• Support for Goals of Study/Objectivity. I support the goals of this study and will collect, to the best of my ability, complete and accurate data, and will report the data objectively and without regard to how it might affect the results of this study. I will be objective in all dealings with study participants. I will voice no opinions I may have about assisted housing, assisted housing tenants, and how assisted housing programs are administered, and I will not discuss them with any study participants (including PHA/project staff and households).

• Treatment of Hardcopy Documents. All information I obtain from hardcopy documents will be treated as confidential and not discussed with or shown to any parties not authorized to have access to such information, including (but not limited to) project/PHA staff, other households I may contact, and HUD staff. All paper documents that contain any information specific to a household or household member will be sent to ICF Macro as instructed. No copies of documents with confidential information will be retained after data collection is completed.

• Non-Disclosure of Sensitive Data. I understand that I may have access to sensitive information that is protected under the Privacy Act (5 U.S.C. 522a), which must not be disclosed to unauthorized persons. Any government information made available to me, as a member of the project team, shall be used only for the purpose of carrying out the requirements of this project and shall not be divulged, or made known in any manner, to any person who is not a member of the project team, without written authorization from the project director. I understand that disclosure of any confidential information, by any means, for a purpose or to any extent unauthorized herein, may subject me to criminal sanctions imposed by 18 U.S.C 641.

• Reporting of Disclosures. I shall promptly and immediately report to my field supervisor any knowledge of uses, transmissions, losses or other disclosures (whether intentional or unintentional) of data that are not in accordance with this agreement or applicable law.  In addition and to the maximum extent practical, I shall assist in mitigating any harmful effect of any unauthorized use or disclosure of such data.

My signature below signifies my understanding of, and agreement with the above stipulations.

Field Interviewer Signature: ___________________________

Date: ___________________________