Request for Authorization to Give Assurance of Confidentiality

Status: Original and derived artifacts are available for this document.

Download: pdf

Request for Authorization to
Give Assurance of Confidentiality

Control No:

UNDER SECTION 308(d) OF THE PUBLIC HEALTH SERVICE ACT
NOTE: Do not obtain signature on this form until OS and the Project Officer have agreed on final versions
of the 308(d) Justification, Assurance, and Security Statement.

1. REQUESTED BY:
Name of Project Officer/Principal Investigator:

Bldg:

Carolyn Wright

Roybal

Center/Institute/Office:

Division:

NCHHSTP

DHP

Request Status:

Period of time authorization needed for data collection:
(For OS use only)

New

Amended Request

Extension Request

Rm No.:

From: 09/30/2022

MailStop:

Phone No.:

H24-5

(404) 639-4262

To: 09/30/2027

2. TITLE OF PROJECT:
The National HIV Prevention Program Monitoring and Evaluation (NHM&E) system
(formerly known as "The Program Evaluation and Monitoring System (PEMS)”)

3. JUSTIFICATION STATEMENT
Please attach the justification statement. (See “Assurance of Confidentiality Application Procedure” for further details.

4. APPROVAL OF REQUEST BY CENTER/INSTITUTE/OFFICE DIRECTOR OR DESIGNEE:
Name and Organizational Title: Nelson Adekoya, Senior Health Scientist
Digitally signed by Nelson Adekoya -S12

Signature: Nelson Adekoya -S12 Date: 2024.09.10 12:51:50 -04'00'

Date: 09/10/2024

5. FOR OS USE ONLY:
Transmitted to Confidentiality Review Group
Date:

Confidentiality Review Group recommends:
Approval

Disapproval

Date:

PCU Review Only:
Digitally signed by Joseph Rush Jr -S

Signature: Joseph Rush Jr -S Date: 2024.10.15 16:44:26 -04'00'

Date:

ASSURANCE OF CONFIDENTIALITY IS AUTHORIZED
Digitally signed by Althea M. Grant-lenzy -S11

Signature: Althea M. Grant-lenzy -S11 Date: 2024.10.29 14:51:32 -04'00'

Date:

DIRECTOR, OFFICE OF SCIENCE OR
DEPUTY DIRECTOR OF SCIENCE
CDC 0.970 Revised July 2020 CS316795

SAVE

EMAIL

PRINT