Nondisclosure Affidavit

Attachment C – Template 1

Nondisclosure Affidavit - Federal Employee Version

NONDISCLOSURE AFFIDAVIT

Federal Employee Version

The National Center for Health Statistics collects, compiles, and publishes general purpose vital and health statistics which serve the needs of all segments of the health and health related professions. The success of the Center's operations depends upon the voluntary cooperation of States, of establishments, and of individuals who provide the information required by Center programs under an assurance that such information will be kept confidential and be used only for statistical purposes.

NCHS operates under the authority and restrictions of Section 308(d) of the Public Health Service Act which provides in summary that no information obtained in the course of its activities may be used for any purpose other than the purpose for which it was supplied, and that such information may not be published or released in a manner in which the establishment or person supplying the information or described in it is identifiable unless such establishment or person has consented.

Three specific laws excerpted below provide penalties for unauthorized disclosure of confidential information.

Section 513 of PL 107-347: Whoever, being an officer, employee, or agent of an agency acquiring information for exclusively statistical purposes, having taken and subscribed the oath of office, or having sworn to observe the limitations imposed by section 512, comes into possession of such information by reason of his or her being an officer, employee, or agent and, knowing that the disclosure of the specific information is prohibited under the provisions of this title, willfully discloses the information in any manner to a person or agency not entitled to receive it, shall be guilty of a class E felony and imprisoned for not more than 5 years, or fined not more than $250,000, or both.

18 U.S.C. section 1905: "Whoever, being an officer or employee of the United States or of any department or agency thereof, publishes, divulges, discloses, or makes known in any manner or to any extent not authorized by law any information coming to him in the course of his employment or official duties...which information concerns or relates to the trade secrets...confidential statistical data...except as provided by law; shall be fined under this title, or imprisoned not more than one year, or both; and shall be removed from office or employment."

Privacy Act of 1974, 5 U.S.C. section 552a(i)(l): "Any officer or employee of an agency, who by virtue of his employment or official position, has possession of, or access to, agency records which contain individually identifiable information the disclosure of which is prohibited by this section or by rules or regulations established thereunder, and who knowing that disclosure of the specific material is so prohibited, willfully discloses the material in any manner to any person or agency not entitled to receive it, shall be guilty of a misdemeanor and fined not more than $5,000."

Telework Restrictions. While working on an approved telework agreement (i.e.—situational, long-term, or unscheduled), I agree that I will: 1) not access or send electronically nonpublic use microdata while working at an alternative work site; 2) not access the NCHS CIPSEA Server; and 3) not remove detailed output (e.g., line listings, high-dimension cross-tabulations tables, data run logs, etc.) generated from nonpublic use microdata from NCHS Hyattsville, MD or Research Triangle Park offices unless I’ve obtained prior authorization and clearance from the Office/Division Director or designee owning the data.

I agree to the above telework restrictions regardless of whether or not I currently have an approved telework

agreement on file.

Your signature below indicates that you have carefully read and agreed to follow all NCHS policies and procedures to protect the confidentiality of data collected under these statutes. You also agree not to link NCHS files with any other file that would permit the identification of a person or establishment unless the linkage is conducted under an approved project.

____________________________________ ______________________________ __________________

Name (Type or Print) Signature Date

____________________________________ ______________________________

NCHS Division/Program (type or print) Type of Appointment/Length of Appointment (type or print)

(E.g., ORM, DHNES, DVS, OPBL, DHCS, etc.) (E.g., career or career-conditional/permanent or temporary)

Attachment C – Template 1

Nondisclosure Affidavit - Contractor Version

NONDISCLOSURE AFFIDAVIT

Contractor Version

The National Center for Health Statistics collects, compiles, and publishes general purpose vital and health statistics which serve the needs of all segments of the health and health related professions. The success of the Center's operations depends upon the voluntary cooperation of States, of establishments, and of individuals who provide the information required by Center programs under an assurance that such information will be kept confidential and be used only for statistical purposes.

NCHS operates under the authority and restrictions of Section 308(d) of the Public Health Service Act which provides in summary that no information obtained in the course of its activities may be used for any purpose other than the purpose for which it was supplied, and that such information may not be published or released in a manner in which the establishment or person supplying the information or described in it is identifiable unless such establishment or person has consented.

The laws excerpted below provide penalties for unauthorized disclosure of confidential information.

Section 513 of PL 107-347: Whoever, being an officer, employee, or agent of an agency acquiring information for exclusively statistical purposes, having taken and subscribed the oath of office, or having sworn to observe the limitations imposed by section 512, comes into possession of such information by reason of his or her being an officer, employee, or agent and, knowing that the disclosure of the specific information is prohibited under the provisions of this title, willfully discloses the information in any manner to a person or agency not entitled to receive it, shall be guilty of a class E felony and imprisoned for not more than 5 years, or fined not more than $250,000, or both.

Privacy Act of 1974, 5 U.S.C. section 552a(i)(l): "Any officer or employee of an agency, who by virtue of his employment or official position, has possession of, or access to, agency records which contain individually identifiable information the disclosure of which is prohibited by this section or by rules or regulations established thereunder, and who knowing that disclosure of the specific material is so prohibited, willfully discloses the material in any manner to any person or agency not entitled to receive it, shall be guilty of a misdemeanor and fined not more than $5,000."

Telework Restrictions. While working on an approved telework agreement (i.e.—situational, long-term, or unscheduled), I agree that I will: 1) not access or send electronically nonpublic use microdata while working at an alternative work site; 2) not access the NCHS CIPSEA Server; and 3) not remove detailed output (e.g., line listings, high-dimension cross-tabulations tables, data run logs, etc.) generated from nonpublic use microdata from NCHS Hyattsville, MD or Research Triangle Park offices unless I’ve obtained prior authorization and clearance from the Office/Division Director or designee owning the data.

I agree to the above telework restrictions regardless of whether or not I currently have an approved telework

agreement on file.

Your signature below indicates that you have carefully read and agreed to follow all NCHS policies and procedures to protect the confidentiality of data collected under these statutes. You also agree not to link NCHS files with any other file that would permit the identification of a person or establishment unless the linkage is conducted under an approved project.

____________________________________ ______________________________ __________________

Type or Print Name Signature Date

____________________________________ ______________________________

NCHS Division/Program (type or print) Contract Company

(E.g., ORM, DHNES, DVS, OPBL, DHCS, etc.) (E.g., TRW, NOVA, ORKAND, GEARS, etc.)

Version: 06/17/2013