SFIC Study OMB AppH-SFIC Study Staff Confidentiality Pledge

Appendix H

Study Confidentiality and Non-Disclosure Agreement

School Foodservice Indirect Cost Study: Staff Confidentiality Pledge

CONFIDENTIALITY PLEDGE

I, __________________, understand that I will be allowed access to confidential information and/or records so that I may perform my specific job duties. I further understand and agree that I am not to disclose confidential information and/or records without the prior consent of the appropriate authority(s).

I understand that accessing or releasing confidential information and/or records, or causing confidential information and/or records to be accessed or released, on myself, other individuals, clients, relatives, etc., outside the scope of my assigned job duties would constitute a violation of this agreement.

I understand that all USERID/Passwords to access the School Foodservice Indirect Cost Study Data Collection Database are issued on an individual basis. I further understand that I am solely responsible for all information obtained, through system access, using my unique identification. At no time will I allow any other person to use of my USERID/Password to logon to the School Foodservice Indirect Cost Study Data Collection Database.

By affixing my signature to this document I agree that it is my responsibility to assure the confidentiality of all information, which has been issued to me in confidence, even after my participation in the School Foodservice Indirect Cost Study has ended.

User Signature_____________________________Date________________________

Print or Type User Name __________________________

Title ____________________________________________

Agency/Organization Name ____________________________________________

Address______________________________________________________________

City___________________________ State_____________ Zip__________________

Please send completed “Staff Confidentiality Pledge” forms to:

School Foodservice Indirect Cost Study (USDA/FNS)

Abt Associates Inc.

55 Wheeler St

Cambridge MA 02138

Questions? Please email [email protected].