CCCC_Privacy and Nondisclosure Agreement

APPENDIX CCCC: PRIVACY AND NONDISCLOSURE AGREEMENT
WIC NUTRITION EDUCATION STUDY

Assurance of Privacy

In accordance with the Privacy Act of 1974 [5 USC 552a], RTI International and all its subcontractors are required to comply with the applicable provisions of the legislation, and to undertake all necessary safeguards for individuals against invasions of privacy. RTI International assures each respondent that the responses to this information request will be kept private by RTI International 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 to anyone other than authorized project staff.

Agreement

I, (print employee’s name) an employee of (print employee’s organization), agree to work on the WIC Nutrition Education Study in accordance with the guidelines and restrictions specified below. I understand that compliance with the terms of this agreement is a condition of my assignment with the WIC Nutrition Education Study and that these terms are supplementary to those listed in my contract of employment with (print employee’s organization).

1. I agree to treat as private all case-specific information obtained in the WIC Nutrition Education Study and related matters. I further agree that this covenant of privacy and nondisclosure shall survive the termination of this agreement.

2. I further understand that failure to follow the guidelines below may result in a potential violation of the provisions of the Privacy Act of 1974 (violation of the Privacy Act is a misdemeanor and may subject the violator to a fine of up to $5,000), and potential Institute disciplinary action, including termination. To fulfill these obligations, I will:

1. Discuss private project information only with authorized employees of the WIC Nutrition Education Study.

2. Store private project information as specified by project protocols.

3. Safeguard combinations, keys, and rooms that secure private project information.

4. Safeguard private project information when in actual use.

5. Immediately report any alleged violations of the security procedures to my immediate supervisor.

6. Not photocopy or record by any other means any private project information unless authorized by project leaders or my supervisor.

7. Not in any way compromise the privacy of project participants.

8. Not allow access to any private project information to any unauthorized person.

9. Report any lost or misplaced private project information to my supervisor immediately.

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Employee’s Signature Date

______________________________________

Employee’s Organization

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