SEIS HBCU-UP Release Form

Authorization to Release SEIS Data

The undersigned authorizing agent for grant number:___________ [insert NSF grant number] (a National
Science Foundation’s HBCU-UP awardee institution), grants Systemic Research authorization to publish
and share, either in print and/or electronically via CD or its company’s website at:
http://www.systemic.com/publication.cfm, any and all qualitative and quantitative data contained in said
HBCU-UP institution’s Academic Indicator Report (AIR) based on submitted Self Evaluation Indicator
System (SEIS) (OMB 3145-0136) in the method described and checked below:
_____Full Release to the general public, stakeholders and government entities, etc.
_____Restricted Release to other HBCU-UP awardee institutions, Systemic Research, and the National
Science Foundation
_____Stringent Restricted Release to Systemic Research and the National Science Foundation
Please note that under both Restricted or Stringent Restricted Release, the HBCU-UP Institution’s
individual SEIS data and the AIR will be retained by the National Science Foundation, a federal agency,
and will be an integral part of its Privacy Act System of Records in accordance with the Privacy Act of
1974 and maintained in the Education and Training System of Records 63 Fed. Reg. 264, 272 (January 5,
1998). These are confidential files accessible only to appropriate National Science Foundation (NSF)
officials, their staffs, and their contractors responsible for monitoring, assessing, and evaluating NSF
programs. Only data in highly aggregated form, or data explicitly requested as "for general use," will be
made available to anyone outside of the National Science Foundation for research purposes. Data
submitted will be used in accordance with criteria established by NSF for monitoring research and
education grants, and in response to Public Law 99-383 and 42 USC 1885c.
For example data may be used to report on the progress of NSF’s program investment in accordance with
the Government Performance and Results Act (GPRA). In addition, NSF records (data collected under
OMB 3145-0136) are subject to requests from the public under the Freedom of Information Act (FOIA).
For information on NSF’s policies regarding FOIA please see: http://nsf.gov/home/pubinfo/foia.htm.

I, ______________________________________ (Print name), hereby grant to Systemic Research the
authorization in the method checked off above with the full authority to grant said authorization as an
agent of the participating HBCU-UP institution.
___________________________________________________
(Authorized Signature)
(Date)
___________________________________________________
(HBCU-UP Institution)
OMB 3145-0136 (Expires 11/2004)