Field Interviewer Confidentiality Agreement

ATTACHMENT 10: FIELD INTERVIEWER CONFIDENTIALITY AGREEMENT

Point of Sale Intervention for Tobacco Evaluation (POSITEv)

CONFIDENTIALITY AGREEMENT

I, (print employee’s name), an employee of

(print employee’s organization), agree to work on the Point of Sale Intervention for Tobacco Evaluation (POSITEv)for the U.S. Food and Drug Administration in accordance with the guidelines and restrictions specified below. I understand that compliance with the terms of this agreement is a condition of my assignment with the Point of Sale Intervention for Tobacco Evaluation (POSITEv) and that these terms are supplementary to those listed in my contract of employment with

(print employee’s organization).

a. I agree to treat as confidential all case-specific information obtained in the POSITEv study and related matters. I further agree that this covenant of confidentiality shall survive the termination of this agreement.

b. I further understand that failure to follow the guidelines below may result in a potential violation of the provisions of the Privacy Act of 1974 (violation of the Privacy Act is a misdemeanor and may subject the violator to a fine of up to $5,000), and potential disciplinary action, including termination. To fulfill confidentiality obligations, I will:

1. Discuss confidential project information only with authorized employees involved with the POSITEv.

2. Store confidential project information as specified by project protocols.

3. Safeguard combinations, keys, and rooms that secure confidential project information.

4. Safeguard confidential project information when in actual use.

5. Immediately report any alleged violations of the security procedures to my immediate supervisor.

6. Not photocopy or record by any other means any confidential project information unless authorized by project leaders or my supervisor.

7. Not in any way compromise the confidentiality of project participants.

8. Not allow access to any confidential project information to any unauthorized person.

9. Report any lost or misplaced confidential project information to my supervisor immediately.

/ / .

Employee’s Signature Date

Employee’s Organization

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