Informed Consent for SSA Earnings information

Social Security Administration Authorization Form

To the Participant:

We would like to obtain a history of your earnings and employers from the Social Security Administration from 1970 through 2013. Since most people cannot recall this information very well, we are asking for your permission to obtain it from government records.

The information we are requesting is protected by Federal law and cannot be released to us without your written consent. If you give us your permission to collect this information from the Social Security Administration, we will combine it with other information in this study for research purposes only. The Bureau of Justice Statistics and RTI International are committed to maintaining the privacy and confidentiality of all data obtained from or relating to our survey respondents.

We will remove your name, date of birth, and Social Security number, and release the resulting unidentified statistical information to approved researchers for research purposes only. Additional procedures will be adopted to protect the confidentiality of individuals participating in the survey.

At any point and without penalty, you may withdraw authorization for future data collection from the Social Security Administration by writing to: Project Manager, Survey of Prison Inmates, Bureau of Justice Statistics, 810 7th St., NW, Washington, DC 20531. The Project Manager will transmit to the Social Security Administration the withdrawal of your authorization. From that date, we will no longer collect your information from the Social Security Administration. Withdrawal of authorization does not affect your legal status or any decisions regarding your release from this facility in any way.

Please fill out and sign this page. Please print.

To the Social Security Administration:

Name
	First	Middle	Last

Maiden Name (if applicable)

Month

Day

Year

Date of Birth

Social Security Number

-

-

Authorization for Earnings and Employers Information

I authorize the Social Security Administration to release to the Bureau of Justice Statistics, for use in the Survey of Prison Inmates, information about my earnings and employers from Social Security records for the years 1970 through 2013. It is my understanding that the Bureau of Justice Statistics will protect the privacy and confidentiality of these data.

		Month			Day			Year
Signature of Person Named Above		Today’s Date