Privacy Pledge

Attachment 3:
Privacy Pledge

Screening, Brief Intervention and Referral and Treatment (SBIRT) III Cross-Site Evaluation Project

Assurance of Privacy

RTI International assures each respondent that the privacy of responses to this information request will be maintained by authorized project staff 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, unless such individual has consented to such disclosure, to anyone other than authorized project staff.

Agreement

I have carefully read and I understand the Assurance of Privacy that pertains to the private nature of all data to be handled in regard to this project. As an employee or subcontractor of RTI International, I pledge that I will not disclose any private information obtained under the terms of this contract to anyone other than authorized project staff.

I further understand and agree to comply with the following privacy provisions:

1. Any materials that would permit the identification of participants are to be treated as private. These include both hardcopy records and electronic files.

2. Electronic private records will be maintained and managed in a secure password protected file servers, accessible only to authorized project staff.

2. Hard copy private records must be kept in a locked container or room when not in use.

3. When private records are in use in a room, admittance to the room is to be limited to persons who have signed the project Privacy Pledge.

4. Keys and combinations to locked rooms and containers must be protected from unauthorized access.

5. Information obtained from the data collected or used under this contract may not be released to unauthorized persons.

6. No data, tabulations, or analyses obtained under this contract may be released or used without prior written approval of SAMHSA.

7. Any breach of privacy must be reported immediately to the RTI project director, Dr. Georgia Karuntzos, at 1-866-784-1958, extension 6159.

Name (Print)
Signature		Date

Disposition: Original to Project File; Copy to Employee