Designated Agent Form

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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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0396. 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.


	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 – please select applicable option
[ ] I already have Special Sworn Status [ ] 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


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: 	

Keywords: 	

Time period researcher agent expects to work at the RDC:

From (month/day/year):	/	/	to (month/day/year):	/	/ 	


	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 (<10) 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.

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.




	RDC ID: 	



Signature of Designated Agent:
________________________________________




Subscribed and sworn (or affirmed) before me this	day of	,  		.

At (city)	(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.





*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.