Privacy Pledge

Attachment 8: Privacy Pledge

PRIVACY Pledge

Center for Substance Abuse Treatment (CSAT) Grants for the Benefit of Homeless Individuals (GBHI), Treatment for the Homeless, Cross-site Evaluation

Assurance of Privacy

RTI International assures each respondent that the privacy of responses to this information request will be maintained 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, to anyone other than authorized project staff at RTI International.

Agreement

I have carefully read and I understand the Assurance of Privacy that pertains to the private nature of all data to be handled in regard to this project. As an employee of RTI International, a consultant to RTI, or as a member of the CSAT GBHI Cross-site Evaluation team, including employees of or consultants to Advocates for Human Potential, Danya International or Brandeis University, I pledge that I will not disclose any private information obtained under the terms of this contract to anyone other than authorized project staff at RTI International.

I further understand and agree to comply with the following privacy provisions:

1. Any materials that would permit the identification of survey participants are to be treated as private. These include both hardcopy records and electronic files.

2. Private records must be kept in a locked container or room when not in use.

3. When private records are in use in a room, admittance to the room is to be limited to persons who have signed the project Privacy Pledge.

4. Keys and combinations to locked rooms and containers must be protected from unauthorized access.

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

6. No data, tabulations, or analyses obtained under this contract may be released or used without prior written approval of the CSAT.

7. Any breach of privacy must be reported immediately to the RTI project director, Dr. Nahama Broner, at 1-877-353-3422.

Name (Print)
Signature		Date

Disposition: Original to Project File (Mark Pope, Project Manager); Copy to Staff member

Revised: May 5, 2010