Attachment F -- Confidentiality Pledge

Attachment F – Confidentiality Pledge

Confidentiality Pledge

As a member of the JBA evaluation team, I recognize the importance of maintaining the confidentiality of data collected and of assuring the right of privacy of persons cooperating in this evaluation activity. To establish safeguards for all involved, I agree to abide by the following principles of conduct:

1. All information that is collected by me (or other project team members) from participants is confidential. All participants must be informed that their responses to interviews and survey questions will be kept confidential to the extent permitted by law and are for statistical purposes only. All data (and all copies) are property of the project and are not to be shared with anyone. I will not permit any unauthorized person, including members of my own family, to see any completed documents or forms. I will only discuss information obtained about a respondent with authorized project staff.

2. I agree to treat as confidential and proprietary to the evaluation any and all instruments, materials, and documentation provided or accessed during the course of my service on this evaluation activity. I agree not to copy or duplicate any materials without written permission from the Principal Investigator. I agree to safeguard all study materials and to exercise extreme care to protect them from access by unauthorized persons.

3. I agree to conduct myself at all times in a manner that will obtain the respect and confidence of all participants and other persons with whom I may come into contact in connection with this project. I agree to report any breach of confidentiality to my supervisor immediately.

4. I understand that all data collected for this study are the property of AHRQ and will not be used for any purpose without prior written permission

By signing below, I acknowledge that I have read and understand the assurances that will be provided to participants. I understand that I am prohibited by both the law and this agreement from disclosing any confidential information which has been obtained by this study to anyone other than an authorized member of JBA or OHRP. I understand that any willful and knowing disclosure in violation of the Privacy Act of 1974 (5 U.S.C. 552a) is a misdemeanor and is punishable by a fine of up to $5,000. I agree to abide by the terms of the assurances of confidentiality set forth here.

Staff Name: ______________________________________________

(PLEASE PRINT)

Signature: ___________________________________Date: _______