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Statistical Standards Program

Appendix G: Affidavit of Nondisclosure

___________________________
(Job Title)
___________________________
(Date Assigned to work with NCES Data)
___________________________
(Organization, State or Local Agency)
___________________________
(Organization or Agency Address)
___________________________
(NCES Database or File Containing
Individually Identifiable Information*)

I, _________________________, do solemnly swear (or affirm) that when given access to the subject NCES database or file, I will not -

    (i) use or reveal any individually identifiable information furnished, acquired, retrieved or assembled by me or others, under the provisions of Section 183 of the Education Sciences Reform Act of 2002 (P.L. 107-279) and/or Title V, subtitle A of the E-Government Act of 2002 (PL 107-347) for any purpose other than statistical purposes specified in the NCES survey, project or contract;

    (ii) make any disclosure or publication whereby a sample unit or survey respondent (including students and schools) could be identified or the data furnished by or related to any particular person or NAEP school under these sections could be identified; or

    (iii) permit anyone other than the individuals authorized by the Commissioner of the National Center for Education Statistics to examine the individual reports.

_____________________________
(Signature)

[The penalty for unlawful disclosure is a fine of not more than $250,000 (under 18 U.S.C. 3571) or imprisonment for not more than five years (under 18 U.S.C. 3559), or both. The word "swear" should be stricken out when a person elects to affirm the affidavit rather than to swear to it.]

City/County of _______________ Commonwealth/State of ___________
Sworn to and subscribed before me this _______________ day of
_______________, 20________. Witness my hand and official Seal.



_________________________
(Notary Public/Seal)
My commission expires____________________

* Request all subsequent followup data that may be needed. This form cannot be amended by NCES, so access to databases not listed will require submitting additional notarized Affidavits.

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