Multicultural youth aged 13-17 in the select media markets recruiting through social media and online panels - Pre-test online survey

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION

COMMITMENT TO PROTECT NON-PUBLIC INFORMATION
EMPLOYEE AGREEMENT
Whereas access to non-public information from the files of the Food and Drug Administration (FDA) is required
in the performance of my official duties, under Contract Number
between FDA and my
employer
I, on this
day of
, 20
hereby agree that I shall not further release,
publish or disclose such information and that I shall protect such information in accordance with the provisions
of 21 U.S.C. 331(j), 21 U.S.C. 360j(c), 18 U.S.C. 1905 and other pertinent laws and regulations governing the
confidentiality of non-public information.
I understand the provisions of 21 U.S.C. 331(j), 21 U.S.C. 360j(c), 18 U.S.C. 1905 and that I am subject to
criminal penalties prescribed by law for any violation(s) thereof.

Signature:

Date:

Type or Print Name:
Witnessed by:

Date:

Type or Print Name:

DESCRIPTION OF INFORMATION RELEASED:

FORM FDA 3398 (10/10)

PSC Graphics (301) 443-1090

EF