APPENDIX 4 Confidentiality Agreement 10-18-2012

OMB Control No.: 0584-0523

Expiration Date: xx/xx/xxxx

APPENDIX 4 Sample Confidentiality Agreement

CONFIDENTIALITY AGREEMENT

I hereby agree to keep confidential all information discussed during the Interview/Focus Group in which I am participating in (location, date, time) being conducted by (name of contractor performing service) on behalf of the USDA, Center for Nutrition Policy and Promotion.

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Signature of Participant Date

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Name of Participant

(name of contractor performing service) hereby agrees to keep confidential all information discussed during the (Interview/Focus Group) held in (location, date, time) on behalf of the USDA, Center for Nutrition Policy and Promotion.

_________________________________________ ________________________

Signature of Authorized Personnel Date

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Name of Authorized Personnel

[RESEARCH FACILITY] hereby agrees to keep confidential all information discussed during the (Interview/Focus Group) held in (location, date, time) on behalf of the USDA, Center for Nutrition Policy and Promotion.

_________________________________________ ________________________

Signature of Authorized Personnel Date

_________________________________________

Name of Authorized Personnel