Designated Agent F Designated Agent Form

OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number for
this project is 0930­NEW. Public reporting burden for this collection of information is estimated to average 40
minutes per respondent per year, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57A,
Rockville, Maryland, 20857.

SAMHSA

RDC ID:

SAMHSA Designated Agent Form
Research Data Center (RDC)
To be completed by each researcher

The personal information being requested below will be kept confidential and will be only be used for
identifying a researcher who may be granted designated agent status. The information below will be
protected under the Privacy Act of 1974. Providing this information is strictly voluntary; however, not
providing the information will prevent you from being considered for agent status.
PART A: Contact Information
Name (Last, First, Middle)
Date of Birth (MM/DD/YYYY)
US citizen (Yes or No); If not,
provide country of citizenship.
Local home address (street,
city, state, zip code)
Home phone number
Cell phone number
Personal e-mail address
Census Special Sworn Status – [ ] I already have Special Sworn Status
please select applicable option [ ] I will apply for Special Sworn Status
[ ] I do not need Special Sworn Status – analytical work will not take
place in a Federal Statistical RDC
Employer name
Work address (street, city,
state, zip code)
Work phone number

OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX
Work e-mail address
Name of supervisor
Supervisor phone number
Supervisor e-mail address
PART B: Project Information
Provide project title (as listed in the approved project proposal) and up to five keywords that describe the
project.
Project Title:

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SAMHSA Designated Agent Form: v0720

OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX
Keywords:
Time period researcher agent expects to work at the RDC:
From (month/day/year):

/

/

to (month/day/year):

SAMHSA

/

/

RDC ID:

PART C: Affidavit of Non-Disclosure
I, (print name)
, do solemnly swear (or affirm) that I will
observe all policies and procedures to protect the confidentiality of data to which I will have
access to in the RDC as set forth in the attached document Procedures and Costs for Service at
the Research Data Center.
I will not disclose confidential information, either while as an agent or after release from agent
status that are contained in data files, lists, or reports created from using restricted-use data,
which data are protected under the Confidential Information Protection and Statistical
Efficiency Act (CIPSEA) of 2002 (P.L. 107-347, title V, 44 U.S.C. 3501 note). I have read and
understand the penalties* set forth under CIPSEA.
I will only conduct analyses related to the research question(s) for which I have received
approval. I will not use any technique or other data to learn the identity of any person,
establishment, or sampling unit in the confidential data files.
I agree that I will not remove any confidential data from the RDC. Similarly, I will not remove
any files, output, or programs onto transportable electronic media.
I understand that the output from data analyses will be reviewed by an RDC staff member for
disclosures of confidential data. It is my responsibility to protect these data and resulting output
in order to prevent additional risk to the persons or establishments who provided the data. If I
discover or can inadvertently deduce small cells (<5) or person-level information, it is my
responsibility to not share this information with anyone or publish it, and I will immediately
bring this to the attention of an RDC staff member.
I understand that the deliberate violation of any of these conditions may result in cancellation
of my data access agreement and I may be escorted from the RDC by authorized Federal
Protection Service staff. I may also be barred from any future use of the NCHS/Census RDCs
upon review and determination by the sponsor of the data to protect the integrity and
confidentiality of the data.
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SAMHSA Designated Agent Form: v0720

OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX

I am also aware that I can be held legally liable for any harm incurred by persons or
establishments contained in the data I have access to, which may result from my activities that
deviate from RDC rules, procedures and standards of conduct.
If I have questions about RDC rules or procedures or other concerns, it is my responsibility to
ask an RDC staff member.
I understand that deliberately making a false statement in any matter within the jurisdiction of
any Department or Agency of the Federal Government violates Title 18 U.S.C. 1001 and is
punishable by a fine or up to five years in prison or both.

SAMHSA

RDC ID:

Signature of Designated Agent:

Subscribed and sworn (or affirmed) before me this
At (city)

day of

,.

.

(state)

[SEAL]

Notary Public Signature:
My commission expires:

Title (Officer/Notary Public):

Note: The oath of non-disclosure must be administered by a person specified in 5 U.S.C. §2903. The word “swear,” wherever it
appears above, can be stricken out when the agent elects to affirm rather than swear to the affidavit; only these words may be
stricken, and only when the agent elects to affirm the affidavit.

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OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX

*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 five years, or fined
not more than $250,000, or both.

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