Appendix L SOPE Staff Confindentiality Pledge

OMB Control Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Appendix L

Confidentiality Pledge

Evaluation of Technology Modernization for SNAP Benefit Redemption through Online Transactions: Staff Confidentiality Pledge

CONFIDENTIALITY PLEDGE

I, __________________, understand that I will be allowed access to confidential information and/or records so that I may perform my specific job duties. I further understand and agree that I am not to disclose confidential information and/or records without the prior consent of the appropriate authority(s).

I understand that accessing or releasing confidential information and/or records, or causing confidential information and/or records to be accessed or released, on myself, other individuals, clients, relatives, etc., outside the scope of my assigned job duties would constitute a violation of this agreement. I further understand that I am solely responsible for all information obtained, through system access, using my unique identification.

By affixing my signature to this document I agree that it is my responsibility to assure the confidentiality of all information, which has been issued to me in confidence, even after my participation in the Evaluation of Technology Modernization for SNAP Benefit Redemption through Online Transactions has ended.

User Signature_____________________________Date________________________

Print or Type User Name __________________________

Title ____________________________________________

Agency/Organization Name ____________________________________________

Address______________________________________________________________

City___________________________ State_____________ Zip__________________

Please send completed “Staff Confidentiality Pledge” forms to:

Robin Koralek

Evaluation of Technology Modernization for SNAP Benefit Redemption through Online Transactions (USDA/FNS)

Abt Associates Inc.

6130 Executive Boulevard

Rockville, MD 20852

Questions? Please email [email protected].