Attach 11 Collaborators Confidentiality Agreement

Agricultural Health Study
Confidentiality Agreement September 2008
You will complete your AHS data request electronically through the online application at the AHS
STaRS website (www.aghealthstars.com), but we must receive the signed Pledge of Confidentiality by
fax. Please fax the signed Pledge of Confidentiality to Amy Miller at 301.294.2085. Be sure to include
your printed name and the title of the project.
AGRICULTURAL HEALTH STUDY
Pledge of Confidentiality for Collaborators - Prior to receiving AHS data it is required that
collaborators review and sign the following pledge of confidentiality.
I hereby certify that I will keep completely confidential all information arising from Agricultural Health
Study data concerning individual respondents to which I gain access. I also certify that I will abide by all
requirements of the NCI Institutional Review Board (IRB) and other applicable IRBs. Beyond the
research team, I will not discuss, disclose, disseminate, or provide access to survey data and identifiers
except as authorized in writing by the Agricultural Health Study Executive Committee. I shall use the
Agricultural Health Study data only for approved purposes. I am also aware that I am responsible for the
compliance of all other personnel under my supervision who have access to the data provided to me by
the AHS. I agree to report any breaches in confidentiality to the Executive Committee within 24 hours of
their being discovered. I give my personal pledge that I shall abide by this assurance of confidentiality.

Name (Signature) _______________________________________ Date _________________
Name (Print) _________________________________________________________________
Project Title: __________________________________________________________________
Mailing Address (This should be a street address so that Federal Express will deliver to it):
Address 1____________________________________________________
Address 2____________________________________________________
City________________________________________________________
State___________________________________________
Zip____________________________________________