Attachment 5 2019 RTI Staff Privacy Pledge

Staff Privacy Pledge

Pursuant to Title 28 of the Code of Federal Regulations, Part 22, project staff has an obligation to those we interview to protect their identities and the information they provide to the Health Center Patient Survey. The identity of persons interviewed and the related data are to remain private. Disclosure of identities and related information is strictly forbidden. Contents of interviews are not to be discussed with anyone except project staff, and only as it is necessary to complete the assigned work. Additionally, sensitive interview information should not be discussed anywhere it could be overheard by persons who are not authorized to know this information. There are exceptions to the mandate of privacy. If you reasonably suspect that a participant is in immediate danger, intends to harm someone else, or is a victim or perpetrator of child abuse, you may be required to inform the appropriate authorities according to project protocol and in compliance with state and local law.

As a member of the Health Center Patient Survey staff, I, ____________________________,

agree that I will protect the privacy of all information identifiable to a person that is collected in the conduct of my work for the project.

I agree that I shall not discuss any identifiable information that I may learn of during the course of my employment with anyone other than project staff members who have a need-to-know this information.

I agree to follow the procedures established by the project to prevent unauthorized access to information identifiable to a private person.

I understand that my signing this agreement is a condition of my employment as part of the

Health Center Patient Survey project's contractor staff.

_{Full Legal Name (please print):}

Signature _________________________________________ Date _______________

Original to Field Supervisor Yellow Copy to Field Interviewer