I, [name of individual], do solemnly [swear or affirm] that when given access to the [title of data to be provided] provided by [name of the agency or school], I shall not:
2. Make any release or publication whereby an individual could be identified or the data furnished by or related to any particular person can be identified; or
3. Permit anyone other than the individuals authorized by [name of the agency or school] to examine the individual reports.
The penalty for unlawful release is [maximum penalties as specified by the applicable laws and provide citations].
Notary Public and Seal: ____________________________
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