SSA-9902 Confidentiality Agreement

OMB Control No 0960-0754
Expiration Date: XX/XX/XXXX
Purpose: This form is for all users of SSA sensitive data to certify that they understand SSA’s security, confidentiality and
ethics requirements.
I understand the SSA security, confidentiality and ethics requirements and agree that:
1.

I will comply with all the confidentiality and legal requirements as stated in the contract, Memorandum of Agreement
(MOA), or other documentation when using SSA sensitive data at the following secure site (e.g. stand alone computer in
locked room at federal/state agency)
_________________________________________________________________________________
_________________________________________________________________________________
I will only work with SSA data at the above centralized secure site. I will not remotely connect to SSA data from any
alternate work location or from my home. I will not transport SSA data to any other location.

2.

I will follow all security and safeguard provisions as described in the SSA Data Protection Plan when using SSA
sensitive data.

3.

I agree not to construct and maintain, for a period longer than stated in the contract, MOA, or other documentation, any
file containing SSA sensitive data unless explicitly agreed to by SSA in writing.

4.

I agree not to link any other data to the SSA sensitive data described in the contract, MOA, or other documentation or
any derived dataset (s) unless explicitly agreed to by SSA in writing.

5.

I will use proprietary software, i.e. computer software that complies with Federal copyright laws and licensing
agreements.

6.

I agree to keep confidential any third-party proprietary information that may be entrusted to me as part of the contract,
MOA, or other documentation.

7.

I will not release or disclose any information subject to the Privacy Act of 1974, section 6103 of the Internal Revenue
Code, SSA Regulation 1 (20 C.F.R. Part 401), and section 1106 of the Social Security Act to any unauthorized person.

8.

I understand that I may be subject to a site inspection (s) by SSA to ensure that adequate security safeguards, controls
and confidentiality are maintained as specified in the SSA data protection plan and in the contract, MOA, or other
documentation.

9.

I understand that disclosure of any information to parties not authorized by SSA may lead to civil or criminal prosecution
under Federal law and/or regulations.

10.

I understand that I can be subject to a personnel security and suitability background investigation.

________________________________________
User Signature
________________________________________
Print User Name Clearly

___________________________________
Date
____________________________________
Title/Affiliation

___________________________________________________________________________________________
Clearly print a description of your role/function for this research (e.g. authorized user/analyst of the data received
From SSA)

SSA-9902

SSA will insert the following revised PRA Statement into the form at its next scheduled
reprinting:
Paperwork Reduction Act Statement - This information collection meets the requirements of 44
U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of Management and Budget control number. We
estimate that it will take about 4 hours to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.

SSA-9902

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information to facilitate your request for research and statistical purposes.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may result in the delay or denial of your application.
We rarely use the information for any purpose other than the reasons explained above. However,
we may use it for the administration and integrity of our programs. We may also disclose the
information to another person or to another agency in accordance with approved routine uses,
including, but not limited to the following:
1.

To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs); and

2.

To facilitate statistical research, audit, and investigatory activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of the
Census and to private entities under contract with us).

A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice entitled, Disability Studies, Surveys, Records, and Extracts (Statistics), 60-0196.
This notice, additional information regarding our programs and systems are available on-line at
www.socialsecurity.gov or at your Social Security office.