Privacy Agreement

OMB No. 0920-1154

GenIC Clearance for CDC/ATSDR

Formative Research and Tool Development

Youth Audience Message Testing of Substance Use Prevention Messages

Attachment 7 - Privacy Agreement

Contact: Jasmine Kenney, MPH

Communication Branch

Division of Overdose Prevention (DOP)

National Center for Injury Prevention and Control (NCIPC)

Centers for Disease Control and Prevention (CDC)

4770 Buford Hwy NE, MS S106

Atlanta, Georgia 30341

Phone: 770-488-5423

Email: gnk2@cdc.gov

Project Staff Agreement of Privacy

Ensuring the privacy of all reports, records and files containing client names and/or identifying information is critically important to the Centers for Disease Control and Prevention (CDC) and Fors Marsh.

I, _______________________, agree to provide recruitment/screening, research/analysis, and/or advisory support services for the benefit of Fors Marsh in conjunction with the Fors Marsh/CDC project, Youth Audience Message Testing of Substance Use Prevention Messages.

Further, I

____ hereby accept all duties and responsibilities of performing specified support tasks and will do so personally in accordance with the training and guidelines set out by Fors Marsh/CDC;

____ will not engage the services of another person or organization for the purpose of performing specified support tasks for me without prior written approval from Fors Marsh/CDC;

____ promise to perform only the support tasks specified by Fors Marsh and will not conduct any auxiliary services without the approval of Fors Marsh/CDC;

____ agree to treat as private and proprietary to Fors Marsh/CDC any and all project materials, and documentation provided or accessed while employed on this project;

____ am aware that any information collected is very important, and therefore agree that all work completed will be of high quality and performed in compliance with project guidelines;

____ agree to keep all client-related project documents and records, as well as any identifying information, closed and locked in accordance with the principles set forth by Fors Marsh/CDC;

____ agree to never discuss sensitive office issues or records outside of the office setting, nor confirm or deny any specific person’s participation in the project;

____ agree to act professionally in a manner that will obtain the respect and confidence of all individuals participating in this project from whom information will be collected and not betray their confidence by divulging information obtained to anyone other than authorized representatives of Fors Marsh/CDC;

____ agree to report any known or suspected breaches of confidentiality to Fors Marsh/CDC; and

____ understand that my obligations to maintain the confidence and privacy of the project and participants’ personal information under this agreement will survive the termination of any assignment and my affiliation with Fors Marsh/CDC.

Signature

Date

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)