Site Visit Confidentiality Agreement email and form

OMB#: 0584-0523

Expiration Date: 12/31/2012

Appendix K

Confidentiality Agreement e-mail and form

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB Control number. The valid OMB number for this collection is 0584-0523. The time required for this information collection is estimated to average 10 minutes per response, including the time to review, sign and return this confidentiality agreement.

We appreciate your interest in participating in our site visit interview on best practices in nutrition education programs and recommendations for improvements to those programs, as part of our project with USDA Center for Nutrition Policy and Promotion and USDA Food and Nutrition Service. Before the site visit interview, please sign, include your name in print, and date this confidentiality agreement form and then return it by fax, email (scanned copy), or mail to: {insert name and contact information including mailing address, email, and fax number}. Alternatively, you can hand it to the interviewer before the site visit.

If you have any questions, please feel free to contact {insert name and contact information}.

Thank you.

CONFIDENTIALITY AGREEMENT

I hereby agree to keep private all information discussed during the site visit in which I am participating on (date, time) being conducted by (name of contractor performing service) on behalf of the USDA, Center for Nutrition Policy and Promotion, and Food and Nutrition Service.

_________________________________________ ________________________

Signature of Participant Date

_________________________________________

Name of Participant

(name of contractor performing service) hereby agrees to keep private all information discussed during the site visit held on (date, time) on behalf of the USDA, Center for Nutrition Policy and Promotion, and Food and Nutrition Service.

_________________________________________ ________________________

Signature of Authorized Personnel Date

_________________________________________

Name of Authorized Personnel

(name of contractor performing service) hereby agrees to keep private all information discussed during the site visit held on (date, time) on behalf of the USDA, Center for Nutrition Policy and Promotion, and Food and Nutrition Service.

_________________________________________ ________________________

Signature of Authorized Personnel Date

_________________________________________

Name of Authorized Personnel

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