CE 4 3 Affidavit Attachment J

Attachment J: Affidavit of Nondisclosure

____________________________________ ______________________________

(Job Title) (Date Assigned to Work with IES Data)

____________________________________

(Organization, State or Local Agency Name)

____________________________________ ____________________________

(Organization or Agency Address) (NCES Database or File Containing

Individually Identifiable Information*)

I, __________________________________, do solemnly swear (or affirm) that when given access to the subject IES database or file, I will not -

(i) use or reveal any individually identifiable information furnished, acquired, retrieved or assembled by me or others, under the provisions of Section 183 of the Education Sciences Reform Act of 2002 (P.L. 107-279) for any purpose other than statistical, research, or evaluation purposes specified in the IES survey, project or contract;

(ii) make any disclosure or publication whereby a sample unit or survey respondent (including students and schools) could be identified or the data furnished by or related to any particular person or school under these sections could be identified; or

(iii) permit anyone other than the individuals authorized by the Director of the Institute of Education Sciences to examine the individual reports.

___________________________________

(Signature)

[The penalty for unlawful disclosure is a fine of not more than $250,000 (under 18 U.S.C. 3571) or imprisonment for not more than five years (under 18 U.S.C. 3559), or both. The word "swear" should be stricken out when a person elects to affirm the affidavit rather than to swear to it.]

City/County of _________________ Commonwealth/State of ________________ .

Sworn to and subscribed before me this _______________ day of

_______________, 20________ . Witness my hand and official Seal.

____________________________________ My commission expires__________________ .

(Notary Public/Seal)

* Request all subsequent follow-up data that may be needed. This form cannot be amended by NCES, so access to databases not listed will require submitting additional notarized Affidavits.

Form last revised 09/27/12