Attach6 A CDC Data Systems ROB System Users

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Centers for Disease Control and
Prevention
The National Center for HIV/AIDS, Viral Hepatitis,
STD, & TB Prevention

CDC Data Systems

Rules of Behavior for the Use of CDC Data Systems

Agency Users

July 2011

Sensitive but Unclassified (SBU)
This document contains information that may be exempt from public release under the Freedom of Information Act (FOIA)
(5 U.S.C. 552), exemption 2 applies. Approval by the Centers for Disease Control and Prevention Document Control
Officer (OSEP) and the CDC FOIA Officer, prior to public release via the FOIA Office is required.
This document was prepared by the Data System and Analysis Team (Shubha Rao, swr2@cdc.gov and John Beltrami,
hzb3@cdc.gov).

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TABLE OF CONTENTS
1. INTRODUCTION ............................................................................................. 2
1.1 PURPOSE AND SCOPE .................................................................................... 2
1.2 LEGAL, REGULATORY, AND POLICY REQUIREMENTS .......................................... 2
1.3 STATEMENT OF SYSTEM POLICY...................................................................... 3
1.4 NO EXPECTATION OF SYSTEM USE PRIVACY .................................................... 4
1.5 PENALTIES FOR NON-COMPLIANCE.................................................................. 4
2. USER RESPONSIBILITIES .............................................................................. 4
2.1 ETHICAL CONDUCT......................................................................................... 4
2.2 AUTHENTICATION MANAGEMENT ..................................................................... 4
2.2.1 Granting Access ................................................................................... 5
2.2.2 Levels of Access ................................................................................... 5
2.2.3 Terminating Access .............................................................................. 5
2.2.4 Use of Passwords ................................................................................. 6
2.2.5 Administration of Proxies ...................................................................... 6
2.3 INFORMATION MANAGEMENT AND DOCUMENT HANDLING .................................. 6
2.3.1 Storage ................................................................................................. 7
2.3.2 Disposal ................................................................................................ 7
2.3.3 Release of Data .................................................................................... 7
2.3.4 Encryption ............................................................................................. 8
2.3.5 Backing Up Data ................................................................................... 9
2.4 SYSTEM ACCESS AND USAGE ....................................................................... 10
2.4.1 Portable Equipment ............................................................................ 10
2.4.2 Physical Security of Equipment .......................................................... 10
2.4.3 Dial-Up Access ................................................................................... 10
2.4.4 Locking Workstations .......................................................................... 11
2.4.5 Disable Browser Password Caching ................................................... 11
2.5 INCIDENT REPORTING ................................................................................... 11
2.5.1 Breaches of Confidentiality ................................................................. 11
2.5.2 Unauthorized Intrusions ...................................................................... 12
2.6 TRAINING AND AWARENESS .......................................................................... 12
2.7 CDC DATA SYSTEMS SECURITY AGREEMENTS .............................................. 13
3. USER ASSISTANCE AND ADDITIONAL RESOURCES .............................. 13
4. REVISIONS AND RENEWAL......................................................................... 13
5. ACKNOWLEDGEMENT AND AGREEMENT OF RULES OF BEHAVIOR
FOR CDC DATA SYSTEMS AGENCY USERS ................................................. 14

Sensitive but Unclassified (SBU)
This document contains information that may be exempt from public release under the Freedom of Information Act (FOIA)
(5 U.S.C. 552), exemption 2 applies. Approval by the Centers for Disease Control and Prevention Document Control
Officer (OSEP) and the CDC FOIA Officer, prior to public release via the FOIA Office is required.
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1. Introduction
1.1 Purpose and Scope
The purpose of this “Rules of Behavior for CDC data systems Agency Users”
(ROB-AU) is to provide users of CDC data systems users guidelines for policies
and practices related to National HIV Prevention Program Monitoring and
Evaluation (NHM&E) data and web-based reporting. All grantees using CDC
data systems should review the topics discussed in this guide and sign it.
Additional rules of behavior may be appended if required by state or local law or
are otherwise necessary.
For purposes of this document, the term “CDC data systems” refers to CDCfunded Information Technology (IT) systems used for collecting and reporting
NHM&E data.
CDC data systems are browser-based software systems for reporting NHM&E
data. CDC data systems are made available to CDC grantees who wish to use
them for data collection and reporting.
The information presented within this ROB addresses the:
 Scope, boundaries, and applicability of the system rules
 Governing law and policy applicable to the system
 Statements of policy related to expected Agency Users’ behaviors and
responsibilities
 Broad range of consequences possible for policy violation
 Descriptions of CDC data systems Agency Users’ responsibilities
 Listing of any system-specific prohibited actions
 Process for obtaining system help and a listing of additional resources
 Process for publishing and acknowledging revisions
 Formal acknowledgement and agreement mechanism (signature)

1.2 Legal, Regulatory, and Policy Requirements
CDC data systems are part of the CDC System Enterprise Architecture and are
held to a high standard of performance with regard to security. The following
standards were applied to CDC data systems:
Standards Required by Law for Federal Systems


Clinger-Cohen Act of 1996 (Public Law 104-106)
http://www.cio.gov/documents_details.cfm/uid/1F432CB6-2170-9AD7F2F9BFC351F83400/structure/Laws,%20Regulations,%20and%20Guidan
ce/category/IT%20Related%20Laws%20and%20Regulations

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





OMB Budget Circular A-130, Appendix III, Security of Federal Automated
Information Resources
http://www.whitehouse.gov/omb/circulars_a130_a130appendix_iii
Federal Information Security Management Act (FISMA)
http://csrc.nist.gov/groups/SMA/fisma/index.html
HHS Information Security Program Policy HHS-IRM-2004-0002
http://www.hhs.gov/ocio/policy/2004-0002.001.html
National Institute of Standards and Technology Special Publications 800
Series http://csrc.nist.gov/publications/PubsSPs.html
Executive Orders, Directives, Regulations, Publications, Guidance(s)

Compliance requirements for the operation of CDC data systems include
participation in the following processes and filing/signing the relevant
documents:





Certification & Authentication (C&A) process
CDC Capitol Planning Investment Control (CPIC) OMB reporting
Enterprise System cataloguing
Various service agreements that must be executed

Agencies may be required to meet additional data security requirements
based on current legal, regulatory, and policy requirements for the C&A
process.

With respect to these laws and regulations, prohibited uses include:




Accessing or inappropriately using information which is protected by
the Privacy Act, other federally mandated confidentiality provisions,
and/or by OMB Circular A-130, Management of Federal Information
Resources
Violating copyrights or software licensing agreements

1.3 Statement of System Policy
Each user is responsible for helping to prevent unauthorized use of, and access
to, system resources. This duty includes complying with all stated policy
requirements, taking due care and reasonable precautions when handling
system data or using system resources, and in the management and protection
of system authentication controls (e.g., passwords, certificates, etc.). When in
doubt, users are strongly encouraged to contact their local CDC data system
administrator or the system help desk for assistance.

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1.4 No Expectation of System Use Privacy
CDC or local Agency System Administrators may periodically monitor both the
system and user activities for purposes including, but not limited to,
troubleshooting, performance assessment, usage patterns, indications of attack
or misuse, and the investigation of a complaint or suspected incidents or security
breaches. Users are provided system access for the purpose of facilitating
federal, state, local, and agency public health missions.

1.5 Penalties for Non-Compliance
Users who do not comply with the prescribed ROB are subject to penalties that
can be imposed under existing policy and regulation including reprimands,
suspension of system privileges, and suspension from duty, termination, or
criminal prosecution.

2. User Responsibilities
2.1 Ethical Conduct
Users of CDC data systems are only permitted to access: the data that they
enter, the data that belong to their individual organization, and specific data to
which they have been given rights. Using system resources to copy, release, or
view data without authorization is prohibited. Altering data improperly or
otherwise tampering with the system is prohibited. Staff authorized to access
client-specific data are responsible for the protection of confidential information
and must report any breaches.

2.2 Authentication Management
Access to NHM&E data files and CDC data system software must be restricted to
authorized users. Users will be assigned a user account, limiting activities within
the system. The Agency System Administrator will terminate access if employees
leave, change jobs, or breach agency policies. Users who share the same
computer must have separate logins and secure data network security
certificates. Authentication requirements will be determined based on the security
level assessed for the data system or application by CDC’s Office of the Chief
Information Security Officer (OCISO). Users of these applications or data
systems are required to comply with authentication requirements by OCISO. The
Agency System Administrator will be responsible for ensuring that all staff
members that use the application meet all authentication requirements.

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2.2.1 Granting Access
The Agency System Administrator grants access to staff requiring use of CDC
data system software or NHM&E data. The steps in this process for CDC
grantees that choose to use CDC data system software are as follows:
 Application for a security certificate
 Application for CDC data system access (to include a letter from Agency
System Administrator)
This is usually done in writing through the user’s supervisor and should include a
description of the user’s duties related to CDC data systems. Once a certificate
is granted, the Agency System Administrator establishes an account with levels
of access and permissions for that user which should only be necessary to
perform their required duties. Users are assigned a user ID and a means of
authenticating who they are, such as a password. An Agency System
Administrator’s responsibility also includes restricting access to parts of CDC
data systems according to the role of the user, modifying access within the
system when a user’s duties change, and terminating access when employees
leave, change jobs, or breach agency policies.
Users of CDC data systems who have access to confidential data or secured
areas should sign binding, non-disclosure agreements before being given access
to CDC data systems (trainings in the policy and procedures concerning security
and confidentiality are also highly recommended).

2.2.2 Levels of Access
The Agency System Administrator is responsible for restricting access to parts of
CDC data systems according to the role of the user and modifying access within
the system when a user’s duties change. All users do not need access to all
parts of the system. Access to the various parts of CDC data systems should be
restricted based upon the role of the user. For example, typical roles include data
entry, generating reports, system administration, and viewing information. Some
people may need to read information about clients but not enter data. Others
may need to analyze aggregated data but not view case-specific information.
Your Agency System Administrator will assign the roles and access rights for
you.

2.2.3 Terminating Access
As soon as it becomes known that an individual is changing duties within an
agency, leaving the agency, or has breached agency policies, their access will be
modified or terminated. The job-transition protocol of the agency should include
immediate notification to the CDC data system administrator of any change in
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employee status so that the proper actions can be taken to protect the system
and its data.

2.2.4 Use of Passwords
Passwords must be used to confirm user identity. Passwords should be changed
periodically (at least every 60 days) and not shared among staff. Separate
passwords may also be used to protect specific data sets or applications within
the system. For example, a user may need to enter their individual password to
get access to the system, but then may need to enter a second, different
password in order to get access to information about a certain set of clients. The
CDC data system password policy is that the passwords should be at least 8
characters long, contain a mix of at least three of the four types of keyboard
elements (i.e., upper case letters, lower case letters, numerals, and punctuation
marks), and cannot be the individual’s name.

2.2.5 Administration of Proxies
CDC data systems provide the ability to identify and assign proxies (i.e., the
ability to assign one person’s permissions to someone else). Although multiple
users can be granted proxies for an individual, only one user can log in at a time,
as a proxy of another user. Only an Agency System Administrator has
permission to grant and delete a proxy. Rules should be developed at the site
level to determine how long proxies may last and how they should be
administered. All users will comply with the rules of proxy administration.

2.3 Information Management and Document Handling
At the local level, data collection for NHM&E variables may not only exist on the
CDC data system servers. These data may also be on data collection forms or
counselor notes, client files, CD-ROMs, personal digital assistants (PDAs), or
other information storage media. Since all of these types of media may contain
confidential information, the agency must develop policies and procedures for the
use, storage, transmission, and disposal of data for each medium used to record
or store NHM&E data.
The computers (desktop and laptop), PDAs, servers, and other electronic
equipment used to collect, enter, copy, store, analyze, or report NHM&E data
should be under the control of the grantee. The use of equipment related to CDC
data systems, including internet connections, e-mail, photocopiers, facsimile
machines, and other equipment that might be used to copy, transmit, or process
NHM&E data should be regulated by written policies and procedures. The
policies should require that computers have screensaver locks that automatically
engage when the computer is not used for a set brief time period and should
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require that personnel electronically lock their computers when they leave their
desk. In Windows this is done by depressing the Ctrl, Alt, and Delete keys
simultaneously, then depressing the Enter key.

2.3.1 Storage
Agencies should establish policies and procedures that outline when it is
appropriate to export NHM&E data to password protected and encrypted storage
media. All storage media should be clearly labeled. Removable media such as
zip disks, CD-ROMs, etc., should be destroyed or sanitized with disk wiping tools
before reuse or disposal. Storage media, whether removable or fixed, paper or
electronic, containing NHM&E data should be stored in a secured area. Data
removed from secured areas for analysis should be de-identified first. Personal
disks, laptops, thumb drives, and other storage media must not be used to store
confidential NHM&E data. When used for data storage, these devices must
contain only the minimum non-confidential data necessary to perform a given
task, must be encrypted or stored under lock and key when not in use, and
(except for backups) be sanitized immediately following the task completion.
Cleaning crews, maintenance staff, and other unauthorized personnel must be
escorted into secured areas by designated staff. Encryption of data during
storage is recommended.

2.3.2 Disposal
Many states have laws or regulations concerning how long client records must be
stored, and when and how they must be destroyed. Agencies must develop
policies and procedures that comply with these state regulations. When client
records are to be destroyed, these should include not only paper records but also
electronic records. Please note that “deleting” a file or record on the computer
does not actually remove the information from the system. Even overwriting or
formatting the media may not sanitize it; special sanitization programs or physical
destruction of the storage media may be required. Agencies must be sure to
sanitize or destroy hard drives of computers scheduled for disposal or transfer to
staff not authorized to use CDC data systems.

2.3.3 Release of Data
Agencies must develop a written policy and procedure for releasing data. This
policy should be periodically reviewed and modified to improve the protection of
confidential information. Policies concerning the release of de-identified and
aggregate data that prevent indirectly identifying clients through small
denominators should also be established. Access to any data containing
confidential information or case-specific data should be contingent on having a
signed, current, binding non-disclosure agreement currently on file at the
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individual agency. These agreements must include discussion of possible
employee ramifications and criminal and civil liabilities for unauthorized
disclosure of information.
Reporting Data to CDC: Reporting data to CDC should be done according to
the schedule specified by CDC. While data may be entered into CDC data
systems at any time, it is not reported to CDC until the appropriate files are
submitted to CDC through a secure data network by the authorized personnel of
each agency. Policies and procedures should be developed to specify the data
quality assurance process being implemented and the administrative approval
process being followed prior to reporting/submitting data to CDC.
Releasing Data to Partners: In order to assist other agencies in tracking
referrals or for other related public health purposes, agencies may enter into
agreements with other agencies to share limited information about specific
clients. Data sharing should be based upon written agreements and clients
should be advised on how their confidential information will be managed and/or
shared with other agency partners. Agencies must develop policies and
procedures to comply with state regulations regarding release of data.
Releasing Data to the Public: Except under conditions specified in writing and
explained to clients, only authorized staff members who have signed a binding
non-disclosure agreement (and who have a need to know) should be allowed
access to sensitive client-identifying data. Agencies should have a policy and
protocol for releasing de-identified and aggregate data for use in analysis, grant
applications, reporting, and administrative functions. This policy should specify
what data may be released, in what form, to whom data may be released, and
who may approve the release of data.

2.3.4 Encryption
NHM&E data are sensitive, confidential information that may have legal and
personal implications for clients; therefore, data should be protected from
unauthorized access. NHM&E data should always be encrypted during
transmission and often should be encrypted during storage, such as during
collection in the field. Data transmitted to the CDC through the secure data
network are secured through the use of several security controls. However, it is
the responsibility of the grantee to assure security until data are submitted to the
CDC.
If an organization decides to send data to anyone other than CDC, those data
should be encrypted. NHM&E data scanned into the CDC provided scanning
data tools should be encrypted and sent to the CDC via a secure data network
(for reference, this scanning tool will be retired and may not be applicable for
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future data submissions). All data should remain encrypted until entering the
CDC network and reaching the secure data network staff at which time the data
are decrypted.
The following is a list of client variables that will be encrypted in CDC data
systems.
Client Information
G105 - Last Name
G106 - First Name
G107 - Middle Initial
G108 - Nick Name
G109 - Aliases
G110 - Date of Birth-Month
G111 - Date of Birth-Day
G125 - Physical Description
G128 - Address Type
G129 - Street Address 1
G130 - Street Address 2
G131 - City
G132 - County
G133 - State
G134 - Zip Code
G135 - Phone Number (Day)
G136 - Phone Number (Evening)
G137 - Primary Occupation
G138 - Employer
"Table G1 Notes"

Partner Information
PCR203 - Last Name
PCR204 - First Name
PCR205 - Middle Initial
PCR206 - Nickname
PCR210 - Date of Birth-Month
PCR211 - Date of Birth-Day
PCR219 - Physical Description
PCR220 - Address Type
PCR221 - Street Address 1
PCR222 - Street Address 2
PCR223 - City
PCR224 - State
PCR225 - Zip Code
PCR226 - Phone Number (Day)
PCR227 - Phone Number (Evening)
PCR228 - Primary Occupation
PCR229 – Employer
"Table PCR2 Notes"

2.3.5 Backing Up Data
CDC regularly backs up all NHM&E data stored on CDC database servers. CDC
data system data that are not yet transmitted, either because they have not yet
been entered in the system or because the data are not being stored on CDC
servers, must be backed up periodically by the grantee. Frequency of backup
should depend upon how often the data change and how significant those
changes are, but should be done based on a fixed schedule that is part of the
normal maintenance of the system. Backup copies should be tested to make
sure they are actually usable; copies should be stored under lock and key in a
secure area and a separate copy of data kept at a secure off-site location if
possible.

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2.4 System Access and Usage
2.4.1 Portable Equipment
While the use of portable computers has its advantages, it also creates additional
security risks, such as loss or theft of the computer and data it stores. If
computers are used outside the office, agencies should establish policies
regarding physical security (e.g., the computer should be locked to an immovable
object), and digital security (e.g., the computer should be protected with a unique
username, complex password, and sensitive data should be encrypted). Laptop
computers and other portable hardware that receive NHM&E data should store
those data in encrypted formats. Laptops should employ whole disk encryption
in order to protect any sensitive data that may be stored on the hard drive. No
security certificates for CDC data systems should be saved or stored on portable
media.

2.4.2 Physical Security of Equipment
CDC data system Agency System Administrators should maintain an inventory of
all system hardware and software provided to system users, and periodic audits
should be conducted to account for all assets. Visitors or unauthorized personnel
should not be allowed unescorted access to areas containing computers holding
NHM&E data. All computer equipment should be protected by surge suppressors
and emergency battery power to prevent data loss in case of fluctuations in the
power supply. All computers and other equipment used for CDC data systems
should be housed or stored in secure areas and physically attached to an
immovable object, if possible. All rooms where NHM&E data are stored in
computers or on paper or other storage media should be locked at all times when
not in use, and it should be known with whom the keys reside.

2.4.3 Dial-Up Access
The grantee must develop and document a policy regarding dial-up or other
external access to their work location computer system for the purposes of
accessing CDC data systems or NHM&E data. Since the CDC data systems
contain sensitive, confidential information, dial-up or other external access to the
system is strongly discouraged as this creates more opportunities for
unauthorized often malicious intrusion into the system. If external access is
permitted, it should be restricted to the minimum number of persons possible,
and additional security measures should be taken to ensure identification and
authentication to obtain access in addition to restricting access to as few as
possible.

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2.4.4 Locking Workstations
All users should secure their workstations before leaving them. Automatic screen
saver locks should also be set to engage whenever the system is left idle (e.g.,
15 minutes of inactivity). In order to unlock the screensaver, the system should
require entry of the user’s ID and password.

2.4.5 Disable Browser Password Caching
All CDC data system users will be accessing the application through a web
browser (i.e., Internet Explorer) and should disable the ability of their web
browser to cache (save) their passwords. This will prohibit others who use your
computer to have access to passwords or forms with personal information that
the web browser has cached for you. To disable this option, open a new Web
browser, and select Internet Options from the Tools menu.

2.5 Incident Reporting
2.5.1 Breaches of Confidentiality
A breach of confidentiality is any failure to follow confidentiality protocols,
whether or not information is actually released. This includes a security infraction
that results in the release of private information, with or without harm to one or
more individuals. All suspected or confirmed breaches of confidentiality or
security involving personally identifiable information (PII) such as names,
addresses, identification numbers, dates (except year), etc. should be reported to
the CDC Information Systems Security Officer (phone 404.639.1806; email:rxv2@cdc.gov) and the CDC Division of HIV/AIDS Prevention (DHAP)
Program Evaluation Branch (PEB) Data Security Steward (phone: 404-639-0938;
e-mail: dad5@cdc.gov) within one hour of discovery. All other suspected
breaches of confidentiality or security (e.g., possible viruses, hackers, password
divulgence, lost or misplaced storage media without PII, failure to follow secure
storage policies, etc.) should be reported immediately to the Agency System
Administrator. The Agency System Administrator will determine the cause,
develop and implement process improvements, and/or determine if the incident
should be reported to the CDC Information Systems Security Officer and DHAP
PEB Data Security Steward. In determining whether a non-PII breach of NHM&E
data or records should be reported to CDC, Agency System Administrators
should consider reporting such breaches to CDC if there is a strong possibility
that PII will be breached, CDC data and data systems will be compromised, or
that CDC’s public health mission will be negatively impacted.

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At the local level, sanctions for violations of confidentiality protocols should be
established in writing, as part of the organizational policies, and should be
consistently enforced.

2.5.2 Unauthorized Intrusions
Any computer attached to the Internet, such as a CDC data system computer, is
subject to unauthorized intrusions, such as hackers, computer viruses, and
worms. In addition, authorized users may attempt to access parts of the system
for which they do not have access authority. Grantees must take all reasonable
precautions to protect their systems from these types of unauthorized
penetrations. A plan must be developed and implemented to prevent and, if
necessary, recover from changes to the system caused by unauthorized
penetrations of the computer system. Typical precautions include using effective
passwords, installing firewalls and currently updated anti-virus software, making
backup copies of software, saving data at regular intervals so that the system
can be restored to a previous state, and training staff in basic computer security
(such as keeping passwords secret and not downloading materials from the
Internet or other unauthorized software onto computers that have CDC data
system access).

2.6 Training and Awareness
All agency staff dealing with NHM&E data and the CDC data systems should be
trained on policies and procedures established by the agency, the legal aspects
of data collection, and the ethics of their responsibility to the clients. Every new
employee who requires access to NHM&E data and resources must complete
data security training conducted by your agency before access is granted.
Current employees are also required to complete a refresher course on data
security every year. All data security trainings should cover state regulations and
the agency’s policies concerning confidentiality, computer security, and legal
obligations under non-disclosure agreements. Grantee staff should be aware of
common threats to confidentiality and security, contingency plans for breaches of
confidentiality and security, and the penalties associated with breaches of
confidentiality and security. Each agency staff member with access to NHM&E
data should receive CDC data systems training, including security updates.
Personnel are as much a part of a data collection and reporting system as
computer hardware and collection forms. People are usually the weakest link in
any security system. Each agency should have a policy on NHM&E data
confidentiality and security. The confidentiality and security policy must explain
that authorized users are responsible for knowing the confidentiality and security
policies and procedures, challenging unauthorized users, reporting possible
breaches, and protecting equipment and data. Staff should be required to
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annually sign a statement acknowledging that they have been made aware of the
confidentiality and security requirements for the agency. The signed statement
should be kept in the employee’s file.

2.7 CDC Data Systems Security Agreements
In an effort to provide maximum protection of the data that are entered into CDC
data systems, in addition to the physical and system security measures
explained in this document, there will also be an ROB for CDC Data Systems
Agency System Administrators covering all of the additional duties of the System
Administrator. CDC will also be executing a Memorandum of Understanding
(MOU) with each directly funded grantee organization.

3. User Assistance and Additional Resources
For assistance in using CDC data systems, contact your local CDC data system
administrator or the NHM&E Service Center at pemsservice@cdc.gov or 1-888PEMS-311 (1-888-736-7311).

4. Revisions and Renewal
Revisions to this document will be released as needed. Notifications of the
availability of the revised documents will be made through the CDC data systems
announcement function and other established communication channels. Unless
notified otherwise, it will be assumed that all grantees using CDC data systems
accept the revisions. Comments and concerns should be sent to the NHM&E
Service Center at pemsservice@cdc.gov.

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5. Acknowledgement and Agreement of Rules of
Behavior for CDC Data Systems Agency Users
I have read and agree to comply with the terms and conditions governing the
appropriate and allowed use of CDC data systems and NHM&E data as defined
by this document, applicable agency policy, and state and federal law. I
understand that infractions of these rules will be considered violations of CDC
and agency standards of conduct and may result in disciplinary action, including
the possibility of supervisory notification, official reprimand, suspension of system
privileges, suspension from duty, termination, and/or criminal and civil
prosecution.

____________________________________________
(Signature / Date)

________________________________________________________________
(Printed Name)

(Title)

(Agency Name)

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