Attachment G -- Confidentiality Agreement for Contractor Staff

CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT

Development of an Assisted Living Consensus Instrument, Phase II

As a condition of participation on the project, Development of an Assisted Living Consensus Instrument, Phase II, AHRQ contract # HHSA290200600011I, I agree to maintain the confidentiality of all data and information provided to the Abt/UNC Team as part of the field data collection efforts for testing the ALDC provider information tool. I agree that I will not disclose any such information, during or after this project, except to authorized project staff from Abt, SRBI or the project subcontractor at the University of North Carolina at Chapel Hill.

I also agree that, during or after my participation on this project, I will not disclose to anyone other than authorized representatives any memoranda, questionnaires, work plans, or other materials or information furnished to me in the course of this project.

I understand that any violation of this Agreement may be cause for dismissal without notice, and may lead to legal action.

In addition, I agree to the conditions set forth in the AHRQ Affidavit for Contractors below.

AHRQ Affidavit for Contractors

The Agency for Healthcare Research and Quality (AHRQ) collects and analyzes data for the purpose of carrying out policy research and quality analyses. The success of this aspect of the AHRQ program depends upon the voluntary cooperation of States, of establishments, and of individuals who provide the information required by Agency programs under an assurance that such information will be kept confidential and be used only for statistical purposes.

AHRQ operates under the restrictions of Section 903(c) of the Public Health Service Act which provides in summary that no information obtained in the course of its activities may be used for any purpose other than the purpose for which it was supplied, and that such information may not be published or released in a manner in which the establishment or person supplying the information or described in it is identifiable unless that establishment or individual has consented.

Unauthorized disclosure of confidential information is subject to penalty under Title IX of the Public Health Service Act, 42 U.S.C. 299, Section 924(d), which reads as follows: “Any person who violates subsection (c) shall be subject to a civil monetary penalty of not more than $10,000 for each such violation involved. Such penalty shall be imposed and collected in the same manner as civil money penalties under subsection (a) of section 1128A of the Social Security Act are imposed and collected.

The laws excerpted below provide penalties for unauthorized disclosure of confidential information. Their full text is attached: Section 513 of PL 107–347: ‘‘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 5 years, or fined not more than $250,000, or both.’’

Unauthorized disclosure of confidential information is also punishable under The Privacy Act of 1974, Subsection 552a(i)(l), which reads as follows: “Any officer or employee of an agency, who by virtue of his employment or official position, has possession of, or access to, agency records which contain individually identifiable information the disclosure of which is prohibited by this section or by rules or regulations established there under, and who knowing that disclosure of the specific material is so prohibited, willfully discloses the material in any manner to any person or agency not entitled to receive it; shall be guilty of a misdemeanor and fined not more than $5,000.

It is highly important, therefore, that you understand your obligations regarding confidential information. You also agree not to link ALDC files that would permit the identification of the ALDC respondents (and/or respondent establishments) unless the linkage is conducted under an approved project. Your signature below will indicate that you have carefully read and understood the above statements.

PRINT NAME: _____________________________________________ DATE: _________________

SIGNATURE: ______­­­­­­­­­­­­­­­­­­­­__________________________________________________________________

ORGANIZATION: ____________________________________________________________________