Attachment G - Statement of Agreement

Attachment G

Statement of Agreement

Effectiveness and Implementation Trial of the Safe Dates Program

Statement of Agreement

RTI International is conducting an add-on study for the effectiveness evaluation of the Safe Dates Project under contract to the Centers for Disease Control and Prevention (referred to henceforth as “CDC”) as part of the “Effectiveness and Implementation Trial of the Safe Dates Program” (Contract No. 200-2008-F-27085). RTI assures CDC and respondents to the data collection that all information will be protected under the Privacy Act and will be handled in a secure manner 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.

Agreement

I, _____________________________________, therefore understand and agree to comply with the following provisions:

1. When private are in use, access to all such records is limited to persons who have signed the project Statement of Agreement.

2. Private records must be kept in a secured (locked, password-protected, or other access-limited) location when not in use.

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

4. No data, tabulations, or analyses obtained under this contract may be released or used without prior approval of CDC. Any electronic data or hard copy information that would permit identification of individuals will be destroyed within 3 years of completion of the study.

5. Any breach of this agreement must be reported immediately to the RTI Project Director and to the CDC Project Officer.

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Employee’s Signature

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Date

Disposition: Original to project file, copy to employee

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