NASDA Cerification Form

NAS-004

(Rev. 6/09)

NASDA CERTIFICATION OF

CONFIDENTIALITY AND MOTOR VEHICLE INSURANCE

As an Officer, Employee, or Person Acting for or on Behalf of the United States Department of Agriculture in activities related to data collection and preparation of Reports, I fully recognize my responsibility for:

1. Safeguarding Confidential as well as Nonconfidential types of data, records, or information from unauthorized disclosure, destruction, or modification, whether accidental or intentional.

2. Maintaining the minimum motor vehicle insurance coverage required in my State, while driving an automobile in relation to NASDA business.

The authorized representative of National Association of State Department of Agriculture and National Agricultural Statistics Service has placed before me the following:

1. NASS Security Expectations Brochure.

2. Title 18, United States Code, Paragraph 1905, "Disclosure of confidential Information Generally."

3. E-Government Act of 2002, (Public Law 107-347), Title V – Confidential Information Protection and Statistical Efficiency Act (CIPSEA), Section 512, “Limitations on Use and Disclosure of Data and Information.”

4. E-Government Act of 2002, (Public Law 107-347), Title V – Confidential Information Protection and Statistical Efficiency Act (CIPSEA), Section 513, “Fines and Penalties.”

5. NASDA motor Vehicle Insurance Regulation. (Required of all NASDA employees being reimbursed for mileage in connection with NASDA business.)

I certify that I have read the above mentioned material this          day of                                  , 20     , and will abide by them.

Title:                                                          Signature:                                                                         

(Please type or print in ink the following information)

Name:

Street Address:

City, State, & Zip Code:

UNITED STATES CODE

Title 18, Section 1905, Disclosure of Confidential information generally.

Whoever, being an officer or employee of the United States or of any department or agency thereof, publishes, divulges, discloses, or makes known in any manner or to any extent not authorized by law any information coming to him in the course of his employment or official duties or by reason of any examination or investigation made by, or return, report or record made to or filed with, such department or agency or officer or employee thereof, which information concerns or relates to the trade secrets, processes, operations, style of work, or apparatus, or to the identity, confidential statistical data, amount or source of any income, profit, losses, or expenditures of any person, firm, partnership, corporation, or association; or permits any income return or copy thereof or any book containing any abstract or particulars thereof to be seen or examined by any person except as provided by law; shall be fined under this title, or imprisoned not more than one year, or both; and shall be removed from office or employment.

E-Government Act of 2002, (Public Law 107-347), Title V - Confidential Information Protection and Statistical Efficiency Act (CIPSEA),

Section 512, Limitations on Use and Disclosure of Data and Information.

(a) Use of Statistical Data or Information. – Data or information acquired by an agency under a pledge of confidentiality and for exclusively statistical purposes shall be used by officers, employees, or agents of the agency exclusively for statistical purposes.

(b) Disclosure of Statistical Data or Information. –

(1) Data or information acquired by an agency under a pledge of confidentiality for exclusively statistical purposes shall not be disclosed by an agency in identifiable form, for any use other than an exclusively statistical purpose, except with the informed consent of the respondent.

(2) A disclosure pursuant to paragraph (1) is authorized only when the head of the agency approves such disclosure and the disclosure is not prohibited by any other law.

(3) This section does not restrict or diminish any confidentiality protections in law that otherwise apply to data or information acquired by an agency under a pledge of confidentiality for exclusively statistical purposes.

(c) Rule for Use of Data or Information for Nonstatistical Purposes. – A statistical agency or unit shall clearly distinguish any data or information it collects for nonstatistical purposes (as authorized by law) and provide notice to the public, before the data or information is collected, that the data or information could be used for nonstatistical purposes.

(d) Designation of Agents. – A statistical agency or unit may designate agents, by contract or by entering into a special agreement containing the provisions required under section 502(2) for treatment as an agent under that section, who may perform exclusively statistical activities, subject to the limitations and penalties described in this title.

Section 513, Fines and Penalties.

Whoever, being an officer, employee, or agent of an agency acquiring information for exclusively statistical purposes, having taken and subscribed the oath of office, or having sworn to observe the limitations imposed by Section 512 (above), comes into possession of such information by reason of his or her being an officer, employee, or agent and, knowing that the disclosure of the specific information is prohibited under the provisions of this title, willfully discloses the information in any manner to a person or agency not entitled to receive it, shall be guilty of a class E felony and imprisoned for not more than 5 years, or fined not more than $250,000, or both.

NASDA MOTOR VEHICLE INSURANCE REGULATION

As an employee of NASDA, you are not covered under the Federal Tort Claims Act. You must have motor vehicle liability insurance which meets the minimum requirement for your State. You should contact your insurance company to determine if additional coverage is needed. Survey work qualifies as a non-farm business. Insurance companies generally require a higher rate for cars and trucks used in a non-farm business in comparison with vehicles used solely for farm work. NASDA does have comprehensive liability insurance covering their liability in excess of insurance carried by Enumerators. Should you fail to inform you insurance company that you are engaged in a non-farm business with you motor vehicle, you could face possible cancellation of the policy if you are involved in an accident.

Witnessed by:                                                                                   Date:                                      

Representative of National Association of State Departments of

Agriculture or the National Agricultural Statistics Service