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:

1. Use or reveal any personally identifiable information furnished, acquired, retrieved, or assembled by me or others, under the provisions of [citation of applicable laws] for any purpose other than statistical purposes specified in the [name of agreement];

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.

Name: _________________________________________

Title: __________________________________________

Organization: ____________________________________

Date: __________________________________________

The penalty for unlawful release is [maximum penalties as specified by the applicable laws and provide citations].

Notary Public and Seal: ____________________________

 
For questions about the content of this product, please contact Lee M. Hoffman.