Nondisclosure Affadavit

Attachment C – Template 1

Nondisclosure Affidavit - Federal Employee Version

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Affidavit of Non-Disclosure for NCHS Federal Staff

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 is subject to the restrictions of the Privacy Act, 18 U.S.C. section 1905, Section 308(d) of the Public Health Service Act and Title V of the E-Government Act of 2002 (PL 107-347) which provides in summary that information obtained under a pledge of confidentiality may be used only for the purpose for which it was supplied, and may not be disclosed, published or released in identifiable form to anyone not authorized to receive it unless the establishment or person supplying the information has consented.

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

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.”

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.”

Title V of the E-Government Act of 2002 (Section 513 of PL 107-347/Confidential Information Protection and Statistical Efficiency Act or CIPSEA): “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.”

Telework Restrictions for Nonpublic Use Microdata Files. While working at an alternate worksite under an approved Primary or Secondary Telework Agreement, I agree not to access electronically nonpublic use microdata files or access the NCHS CIPSEA Server unless I have a government issued laptop and an approved Request For Access To Restricted Use NCHS Data While Teleworking Form on file with the NCHS Confidentiality Office. Additionally, I agree not to remove detailed output (e.g., line listings, high-dimension cross-tabulations tables, data run logs, etc.) generated from nonpublic use microdata files from NCHS offices located in Hyattsville, MD, Research Triangle Park, NC, Atlanta, GA, or off-site NCHS Research Data Centers to an alternate worksite 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 or access nonpublic use microdata files.

Your signature below indicates that you have read the above statutes and agree to protect the confidentiality of NCHS data collected under these statutes.

• I affirm I will observe all policies and procedures to protect the confidentiality of NCHS data I access and that I will not disclose confidential information contained in data files, lists, or reports created using NCHS data, as specified under Section 308(d) of the Public Health Service Act, and under penalties set forth in the Privacy Act, 18 U.S.C. section 1905, and section 513 of PL 107-347 (CIPSEA).

• I 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.

• I will not release confidential data to any other person or organization without the permission of NCHS.

__________________________________ ______________________________ ____________

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)

___________

CDC UserID

Attachment C – Template 2

Nondisclosure Affidavit – NCHS Onsite-Contractor Version

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Affidavit of Non-Disclosure for Non-NCHS Staff (NCHS Onsite-Contractors/Agents)

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 is subject to the restrictions of the Privacy Act, Section 308(d) of the Public Health Service Act and Title V of the E-Government Act of 2002 (PL 107-347) which provides in summary that information obtained under a pledge of confidentiality may be used only for the purpose for which it was supplied, and may not be disclosed, published or released in identifiable form to anyone not authorized to receive it unless the establishment or person supplying the information has consented.

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

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." Paragraph m(1) of section 552a further states that “(1) When an agency provides by a contract for the operation by or on behalf of the agency of a system of records to accomplish an agency function, the agency shall, consistent with its authority, cause the requirements of this section to be applied to such system. For purposes of subsection (i) of this section any such contractor and any employee of such contractor, if such contract is agreed to on or after the effective date of this section, shall be considered to be an employee of an agency.”

Title V of the E-Government Act of 2002 (Section 513 of PL 107-347/Confidential Information Protection and Statistical Efficiency Act or CIPSEA): “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.”

Your signature below indicates that you have read the above statutes and agree to protect the confidentiality of NCHS data collected under these statutes.

• I affirm I will observe all policies and procedures to protect the confidentiality of NCHS data I access and that I will not disclose confidential information contained in data files, lists, or reports created using NCHS data, as specified under Section 308(d) of the Public Health Service Act, and under penalties set forth in the Privacy Act and section 513 of PL 107-347 (CIPSEA).

• I will not release confidential data to any other person or organization without the permission of NCHS.

• I will access confidential NCHS data only from the offices of my organization unless otherwise authorized.

• I am bound by the conditions stated in the executed Designated Agent Agreement with NCHS for the confidential NCHS data I access.

Name (print) _____________________________ Signature __________________________

Organization_____________________________ Date ______________________________

Date NCHS Confidentiality Training Completed: ___________________

http://www.cdc.gov/nchs/about/policy/confidentiality_training/

Attachment C – Template 3

Nondisclosure Affidavit – NCHS Offsite-Contractor Version

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, Maryland 20782

Affidavit of Non-Disclosure for Non-NCHS Staff (NCHS Offsite-Contractors/Agents)

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 is subject to the Privacy Act and operates under the authority and restrictions of Section 308(d) of the Public Health Service Act and Title V of the E-Government Act of 2002 (PL 107-347) which provides in summary that information obtained under a pledge of confidentiality may be used only for the purpose for which it was supplied, and may not be disclosed, published or released in identifiable form to anyone not authorized to receive it unless the establishment or person supplying the information has consented.

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

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." Paragraph m(1) of section 552a further states that “(1) When an agency provides by a contract for the operation by or on behalf of the agency of a system of records to accomplish an agency function, the agency shall, consistent with its authority, cause the requirements of this section to be applied to such system. For purposes of subsection (i) of this section any such contractor and any employee of such contractor, if such contract is agreed to on or after the effective date of this section, shall be considered to be an employee of an agency.”

Title V of the E-Government Act of 2002 (Section 513 of PL 107-347/Confidential Information Protection and Statistical Efficiency Act or CIPSEA): “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.”

Your signature below indicates that you have read the above statutes and agree to protect the confidentiality of NCHS data collected under these statutes.

• I affirm I will observe all policies and procedures to protect the confidentiality of NCHS data I access and that I will not disclose confidential information contained in data files, lists, or reports created using NCHS data, as specified under Section 308(d) of the Public Health Service Act, and under penalties set forth in the Privacy Act and section 513 of PL 107-347 (CIPSEA).

• I will not release confidential data to any other person or organization without the permission of NCHS.

• I will access confidential NCHS data only from the offices of my organization unless otherwise authorized.

• I am bound by the conditions stated in the executed Designated Agent Agreement with NCHS for the confidential NCHS data I access.

Name (print) _____________________________ Signature __________________________

Organization_____________________________ Date ______________________________

Date NCHS Confidentiality Training Completed: ___________________

http://www.cdc.gov/nchs/about/policy/confidentiality_training/