Data Use Agreement Form

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OMB No. 0930-0396
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 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:	

Agreement Regarding Conditions of Access to Confidential Data in the Research Data Center of the National Center for Health Statistics

I (print name) 	 am fully aware that the information contained in (the name of the data file) 		 has been provided to NCHS in accordance with the provisions of Section 308(d) of the Public Health Service Act (42 U.S.C. 242m), with the assurance that it will be used only for health statistical reporting and analysis and will not be published or released in identifiable form. I am also aware that I can be held legally liable for any harm resulting from my activities at the RDC incurred by individuals or establishments who have provided or are described in the information contained in the above work files to which I will have access.

Having read and familiarized myself with Section 308(d) of the Public Health Service Act (42 U.S.C. 242m), I agree:
    1. To only conduct analyses related to the research question(s) for which I have received approval. I will not use any technique in an attempt to learn the identity of any person, establishment, or sampling unit not identified on public use data files.
    2. Not to merge any external data not approved by SAMHSA RDC. NCHS staff will NOT merge any data. This is the responsibility of the researcher.
    3. Not to attempt to remove any data sets from the RDC. Similarly, I will not remove any files, output, or programs to transportable electronic media. RDC staff must review my notes before I leave and will return any programs or output to me via email after review.
    4. Not to use any technique in an attempt to learn what items were suppressed during output review. If I discover or can inadvertently deduce small cells (<10) or any individual-level information, I will not share or publish the information and immediately bring it to the attention of RDC staff.
    5. To hold in strictest confidence the identification of any establishment or individual that may be inadvertently revealed in any documents, discussion, or analysis. If I discover or inadvertently identify an establishment or individual I will immediately bring it to the attention of RDC staff
    6. To comfort myself in a manner consistent with the principles, standards, and rules outlined in the RDC Disclosure Manual, Confidentiality Orientation, and appropriate to a scientific research establishment.
    7. To consult RDC staff anytime I have questions or concerns about disclosure.
Deliberate violation of any of these conditions may result in cancellation of the data access agreement, and the researcher may be escorted from the premises by the duly authorized Federal protection service on duty at NCHS. The researcher may also be barred from any future use of the RDC upon review and determination by the Director of NCHS that this is necessary to protect the integrity and confidentiality of the RDC.
OMB No. 0930-0396
Expiration Date: XX/XX/XXXX


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 5 years in prison or both.

Researcher Signature: 	 Date: