Confidentiality Forms

AFFIDAVIT OF NONDISCLOSURE

______________________________ ____________________________________

(Job Title) (Date of Assignment to Project)

______________________________ ____________________________________

(Organizations, State or local agency or (Project Containing Individually

instrumentality) Identifiable Information)

_________________________________

(Address)

I, _________________________________ , do solemnly swear (or affirm) that when given access to the subject Project database or files , I will not

(i) use or reveal any individually identifiable information furnished,

acquired, retrieved or assembled by me or others under the provisions

of Sections 408 and 411 of the National Education Statistics Act of

1994 (20 U.S.C. 9001 et seq., as amended) for any purpose other than

statistical purposes specified in the project or contract;

2. make any disclosure or publication whereby a sample unit or survey

respondent could be identified or the data furnished by or related to any

particular person under this section can be identified; or

2. permit anyone other than the individuals authorized by the

U.S. Department of Education 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 5 years (under 18 U.S.C. 3559), or both. The word “swear” should be stricken out wherever it appears when a person elects to affirm the affidavit rather than to swear to it.)

Berkeley Policy Associates

EMPLOYEE OR CONSULTANT'S ASSURANCE OF CONFIDENTIALITY OF DATA

Statement of Policy

Berkeley Policy Associates (BPA) is firmly committed to the principle that the confidentiality of individual data obtained through BPA projects must be protected. This principle holds whether or not any specific guarantee of confidentiality was given at time of interview (or self-response), or whether or not there are specific contractual obligations to the client. When guarantees have been given or contractual obligations regarding confidentiality have been entered into, they may impose additional requirements which are to be adhered to strictly.

Procedures for Maintaining Confidentiality

1. All BPA employees and field workers shall sign this assurance of confidentiality. This assurance maybe superseded by another assurance for a particular project.

2. Field workers shall keep completely confidential the names of respondents, all information or opinions collected in the course of interviews, and any information about respondents learned incidentally during field work. Field workers shall exercise reasonable caution to prevent access by others to survey data in their possession.

3. Unless specifically instructed otherwise for a particular project, an employee or field worker, upon encountering a respondent or information pertaining to a respondent that s/he knows personally, shall immediately terminate the activity and contact her/his supervisor for instructions.

4. Survey data containing personal identifiers in BPA offices shall be kept in a locked container or a locked room when not being used each working day in routine survey activities. Reasonable caution shall be exercised in limiting access to survey data to only those persons who are working on the specific project and who have been instructed in the applicable confidentiality requirements for that project.

Where survey data have been determined to be particularly sensitive by the BPA project director in charge of the project or the CEO of BPA, such survey data shall be kept in locked containers or in a locked room except, when actually being used and attended by a staff member who has signed this pledge.

5. Ordinarily, identification numbers shall be assigned to respondents prior to creating a machine-processible record and identifiers such as name, address, and Social Security number shall not, ordinarily, be a part of the machine record. When identifiers are part of the machine data record, the BPA project director shall be responsible for determining adequate confidentiality measures. When a separate file is set-up containing identifiers or linkage information which could be used to identify data records, this separate file shall be kept locked up when not actually being used each day in routine survey activities.

6. When records, with identifiers are to be transmitted to another party, such as for keypunching or key taping, the other party shall be informed of these procedures and shall sign an Assurance of Confidentiality form.

7. Each project director shall be responsible for ensuring that all personnel and contractors involved in handling data on a project are instructed in these procedures throughout the period of performance. When there are specific contractual obligations to the client regarding confidentiality, the project director shall develop additional procedures to comply with these obligations and shall instruct field staff, clerical staff, consultants, and any other persons who work on the project in these additional procedures. At the end of the period of performance, the project director shall arrange for proper storage or disposition of survey data including any particular contractual requirements for storage or disposition. When required to turn over survey data to our clients, we must provide proper safeguards to ensure confidentiality up to the time of delivery.

8. Project directors shall ensure that survey practices adhere to the provisions of the U.S. Privacy Act of 1974 with regard to surveys of individuals for the Federal Government. Project directors must ensure that procedures are established in each survey to inform each respondent of the authority for the survey, the purpose and use of the survey, the voluntary nature of the survey (where applicable) and the effects on the respondents, if any, of not responding.

PLEDGE

I hereby certify that I have carefully read and will cooperate fully with the above procedures. I will keep completely confidential all information arising from data collection concerning individual respondents to which I gain access. I will not discuss, disclose, disseminate, or provide access to data and identifiers except as authorized by BPA. In addition, I will comply with any additional procedures established by BPA for a particular project. I will devote my best efforts to ensure that there is compliance with the required procedures by personnel whom I supervise. I understand that violation of this pledge is sufficient grounds for disciplinary action, including dismissal. I also understand that violation of the privacy rights of individuals through such unauthorized discussion, disclosure, dissemination, or access may make me subject to criminal or civil penalties. I give my personal pledge that I shall abide by this assurance of confidentiality.

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Signature

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PRINT NAME

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DATE