Attachment C Confidentiality Form

OMB Control No.: 0584-0524

Expiration Date: 02/28/2026

APPENDIX C-1 CONFIDENTIALITY AGREEMENT

CONFIDENTIALITY AGREEMENT

(name of contractor performing service) hereby agrees to keep confidential all information discussed during the survey data collection on behalf of the USDA, Food and Nutrition Service.

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Signature of Authorized Personnel Date

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Name of Authorized Personnel

[RESEARCH FACILITY] hereby agrees to keep confidential all information discussed during the survey data collection on behalf of the USDA, Center for Nutrition Policy and Promotion.

_________________________________________ ________________________

Signature of Authorized Personnel Date

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Name of Authorized Personnel

OMB BURDEN STATEMENT: This information is being collected to assist the Food and Nutrition Service in developing a National Outreach Campaign to increase awareness of the health and nutrition benefits associated with specific programs. This is a voluntary collection and FNS will use the information to meet the needs and understand the mindsets of current program participants, as well as those individuals who are eligible but do not participate. This collection does not request any personally identifiable information under the Privacy Act of 1974. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0524. The time required to complete this information collection is estimated to average 2 minutes per response, 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: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0524). Do not return the completed form to this address.