Privacy Agreement

OMB No. 0920-1154

GenIC Clearance for CDC/ATSDR

Formative Research and Tool Development

Formative Research for Spanish-Language

Drug Overdose Messages

Attachment 5 - Privacy Agreement

Contact: Brittney A. Curtis

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 Brunet-García Advertising, (Brunet-García).

I, _______________________, agree to provide recruitment/screening, research/analysis, and/or advisory support services for the benefit of Brunet-García in conjunction with the Brunet-García/CDC project, Message Testing of Spanish-Language Drug Overdose Prevention, Harm Reduction, and Treatment and Recovery Communications for Hispanic/Latinx Populations.

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 Brunet-García/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 Brunet-García /CDC;

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

____ agree to treat as private and proprietary to Brunet-García/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 Brunet-García/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 Brunet-García/CDC;

____ agree to report any known or suspected breaches of confidentiality to Brunet-García/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 Brunet-García/CDC.

Signature

Date

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)