Data Use Agreement Data Use Agreement Form

OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. The OMB control
number for this project is 0930­NEW. Public reporting burden for this collection of information is estimated
to average 40 minutes per respondent per year, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance
Officer, 5600 Fishers Lane, Room 15E57A,
Rockville, Maryland, 20857.

RDC ID:

Agreement Regarding Conditions of Access to Confidential Data in the
Research Data Center of the National Center for Health Statistics
I (print name)
am fully aware that the information contained in
(the name of the data file)
has been provided to NCHS in accordance
with the provisions of Section 308(d) of the Public Health Service Act (42 U.S.C. 242m), with the
assurance that it will be used only for health statistical reporting and analysis and will not be
published or released in identifiable form. I am also aware that I can be held legally liable for any
harm resulting from my activities at the RDC incurred by individuals or establishments who have
provided or are described in the information contained in the above work files to which I will have
access.
Having read and familiarized myself with Section 308(d) of the Public Health Service Act (42 U.S.C.
242m), I agree:
1. To only conduct analyses related to the research question(s) for which I have received approval. I
will not use any technique in an attempt to learn the identity of any person, establishment, or
sampling unit not identified on public use data files.
2. Not to merge any external data not approved by SAMHSA RDC. NCHS staff will NOT merge any
data. This is the responsibility of the researcher.
3. Not to attempt to remove any data sets from the RDC. Similarly, I will not remove any files,
output, or programs to transportable electronic media. RDC staff must review my notes before I leave
and will return any programs or output to me via email after review.
4. Not to use any technique in an attempt to learn what items were suppressed during output review.
If I discover or can inadvertently deduce small cells (<5) or any individual-level information, I will
not share or publish the information and immediately bring it to the attention of RDC staff.
5. To hold in strictest confidence the identification of any establishment or individual that may be
inadvertently revealed in any documents, discussion, or analysis. If I discover or inadvertently
identify an establishment or individual I will immediately bring it to the attention of RDC staff
6. To comport myself in a manner consistent with the principles, standards, and rules outlined in the
RDC Disclosure Manual, Confidentiality Orientation, and appropriate to a scientific research
establishment.
7. To consult RDC staff anytime I have questions or concerns about disclosure.
Deliberate violation of any of these conditions may result in cancellation of the data access
agreement, and the researcher may be escorted from the premises by the duly authorized Federal
protection service on duty at NCHS. The researcher may also be barred from any future use of the
RDC upon review and determination by the Director of NCHS that this is necessary to protect the
integrity and confidentiality of the RDC.

OMB Statement
OMB No. 0930-NEW
Expiration Date: XX/XX/XXXX

Title 18 U.S.C. 1001 Deliberately making a false statement in any matter within the jurisdiction of
any Department or Agency of the Federal Government violates Title 18 U.S.C. 1001 and is
punishable by a fine or up to 5 years in prison or both.
Researcher Signature:

Date: