SSA-9903 SSA Agreement Regarding Conditions For Use of SSA Data

OMB Control No 0960-0754
Expiration Date: XX/XX/XXXX

SOCIAL SECURITY ADMINISTRATION (SSA) AGREEMENT
REGARDING CONDITIONS FOR USE OF SSA DATA

This is an agreement between the Social Security Administration (SSA) and
____________________________________________.
Terms and conditions that apply to the use of SSA data files:
1.

This agreement addresses the conditions under which SSA will disclose and the
recipient will obtain and use the SSA data files indicated in Section 11 of this
agreement. The terms of this agreement can be changed only by a written
modification or by the adoption of a new agreement.

2.

The parties to this agreement agree that SSA retains ownership of the data files
referred to in this agreement.

3.

The recipient warrants that the data files indicated in Section 11 of this agreement
will be used solely for the following purpose(s):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
The data to be used for this project will only be used for research and/or statistical
purposes as delineated in 20 C.F.R. Part 401. No decisions about individuals will
be made based on this information.
All projects for which these data will be used must be specified here. Any other
use will require SSA’s express written authorization.

4.

The following named individual is designated as Custodian of the files on behalf
of the recipient. The Custodian will be responsible for the observance of all
conditions of use and for the establishment and maintenance of security
arrangements to prevent unauthorized use of the data. The recipient agrees to
notify SSA within 15 days of any change of custodianship.

SSA-9903

__________________________________________________________________
(Name of Custodian)
__________________________________________________________________
(Agency/Organization)
__________________________________________________________________
(Street Address)
__________________________________________________________________
(City/State/ZIP Code)
__________________________________________________________________
(Phone number and E-mail Address)
5.

Copies or extracts of the data from the files will be given the same treatment as
original records in the data provided by SSA.

6.

The recipient will provide SSA with a signed confidentiality agreement by all
persons who will have access to the data.

7.

If SSA provides statistical or tabular data or individual-specific records from
which identifiers have been removed or have been masked, the recipient agrees
that no effort will be made by any persons to identify any individual to whom the
particular data in the file pertain. Should an individual be inadvertently identified,
notification of such will be sent to SSA.

8.

The recipient agrees to remove individual identifiers from the files as soon as is
reasonably possible.

9.

The recipient agrees not to publish or otherwise release any information extracted
or derived from an individual record. The recipient agrees that he shall not
disclose, release, or otherwise grant access to the data covered by this agreement
to any person without first obtaining written authorization from the SSA signer of
this agreement or his designee.

10.

The recipient agrees that access to the data covered by this agreement shall be
limited to the minimum number of individuals necessary to achieve the purpose(s)
stated in Section 3.

SSA-9903

11.

12.

The following data files are covered by the agreement:
File
________________________________________

Year(s)
_______________

________________________________________

_______________

________________________________________

_______________

________________________________________

_______________

The parties agree that the files listed in Section 11 of this agreement may be
retained by the recipient until the expiration of the memorandum of agreement.
Upon attainment of the expiration date, the recipient may either:
(1)
(2)
(3)

Request a 1 year extension on a renewal of the agreement;
Return all of the original SSA files and all copies and/or derivative files to
SSA; or
Destroy the original SSA files, all copies and/or derivative files, and send
SSA written certification that this destruction has occurred.

13.

The recipient agrees to provide SSA with a data protection plan for the facility at
which the SSA data will reside. The recipient agrees to establish appropriate
administrative, technical, and physical safeguards to protect the confidentiality of
the data and to prevent unauthorized access to it. The safeguards shall provide a
level and scope of security that is not less than the level and scope of security
established by the Office of Management and Budget (OMB) in OMB Circular
No. A-130, Appendix III – Security of Federal Automated Information Systems
(http://www.whitehouse.gov/omb/circulars/a130/a130.html) which sets forth
guidelines for security plans for automated information systems in Federal
agencies.

14.

The User(s) acknowledges that the use of unsecured telecommunication,
including the Internet, to transmit individually identifiable or deducible
information derived from the file(s) specified in section 11 is prohibited. Further,
the User(s) agrees that the data must not be physically moved or transmitted in
any way from the site indicated in item number 4 without written approval by
SSA.

15.

The recipient agrees that authorized representatives of SSA and/or its Office of
the Inspector General will be granted access to premises where the SSA files
covered by this agreement are kept for the purpose of inspecting security
arrangements and adherence to the terms of this agreement.

SSA-9903

16.

An act by any person to use or release the data listed in Section 11 of this
agreement in a way prohibited herein will cause this agreement to be revoked and
may require immediate return to SSA of all files including derivatives and copies
released to the recipient under the auspices of this agreement.

17.

Signatures

______________________________________________
Manuel de la Puente
Associate Commissioner
Office of Research, Evaluation, and Statistics
Social Security Administration

______________
Date

______________________________________________
Authorizing Official and Title

______________
Date

______________________________________________
Custodian

_______________
Date

SSA-9903

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 4 hours to
read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401.

SSA-9903

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information to facilitate your request for research and statistical purposes.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may result in the delay or denial of your application.
We rarely use the information for any purpose other than the reasons explained above. However,
we may use it for the administration and integrity of our programs. We may also disclose the
information to another person or to another agency in accordance with approved routine uses,
including, but not limited to the following:
1.

To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs); and

2.

To facilitate statistical research, audit, and investigatory activities necessary to
assure the integrity and improvement of our programs (e.g., to the Bureau of the
Census and to private entities under contract with us).

A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice entitled, Disability Studies, Surveys, Records, and Extracts (Statistics), 60-0196.
This notice, additional information regarding our programs and systems are available on-line at
www.socialsecurity.gov or at your Social Security office.