Att H_Confidentiality Stmt

Attachment H

Confidentiality Agreement with Survey Contractor

JBS International, Inc.

Aguirre Division/San Francisco

555 Airport Boulevard, Suite 400

Burlingame, CA 94010-2002

Phone: 650.373.4900

Fax: 650.348.0260

DRAFT AGREEMENT PENDING APPROVAL BY CDC OGC

Non-Disclosure Affidavit

Background: Data collected under this project, the Evaluation Survey for an Educational Intervention for Home Care Workers (the “Project”) funded by the Centers for Disease Control is protected by the Federal Privacy Act and is therefore not publicly available. Several restrictions against disclosure of information apply to your work under this project, and your agreement to the following restrictions is required to carry out your assignment:

Restrictions Against Disclosure

Any materials that would permit the identification or participants (individuals or employers) are to be treated as confidential. These include both hard copy records, papers and electronic files.

Confidential records must be kept in a safe place that is not accessible to persons who are not authorized to view or receive the information.

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

No data, tabulations, or analyses obtained under this Project may be released or used without prior written approval of the Centers for Disease Control.

At all stages of work on this Project, information or records describing either individuals or establishments will be handled with care to avoid disclosure of confidential information. Any dissemination or analysis of the data and issuing of reports will be prepared so as to eliminate any chance that any individual associated with the survey can be identified. Data to be protected includes any information that would permit identification of any individual or establishment

Any breach of confidentiality should be reported immediately to XXXX.

I acknowledge I have read the statement above and understand the importance of safeguarding the confidentiality of the data and that the unauthorized use of such data may lead to sanction under the Federal Privacy Act of 1974 (including criminal and civil penalties), as well as disciplinary action by JBS International, Inc.

I agree, in the performance of the work on this Project, to abide by the restrictions against disclosure requirements and to safeguard the confidentiality of all data in any form.

(continued)

I understand that my acceptance of these conditions is required for my continued access to NAWS data.

I solemnly swear (affirm) that I fully understand that it is my responsibility not to disclose such information collected under this Project, including reports, lists of statements, that might violate the Federal Privacy Act. I will not disseminate or share the data, whether in its original form or aggregated, with anyone other than those who are directly associated with the Project and authorized by the Centers for Disease Control (CDC). I will not publish or release any data without prior written approval from JBS International, Inc. (who will arrange authorization from the CDC), and agree to abide by all conditions listed in this affidavit.

Signature:_________________________________________________________

Name (print): ______________________________________________________

Date: _________________________________