Attachment A-10. Confidentiality Form and Affidavits

CONFIDENTIALITY AGREEMENT

Understanding the Relationship between Implementation of Texas House Bill 5 and Algebra II 

Completion Rates in High Schools

(SEDL under Contract No. ED-IES-12-C-0012)

Safeguards for Individuals Against Invasion of Privacy: In accordance with the Privacy Act of 

1974 (5 United States Code 552a), the Education Sciences Reform Act of 2002 (Public Law 107-

279), the Federal Statistical Confidentiality Order of 1997, the E-Government Act of 2002 

(Public Law 107-347), and the Computer Security Act of 1987, SEDL and all its subcontractors 

are required to comply with the applicable provisions of the legislation, regulations, and 

guidelines and to undertake all necessary safeguards for individuals against invasions of privacy.

To provide this assurance and these safeguards in performance of work on this project, all staff, 

consultants, and agents of SEDL, and its subcontractors who have any access to study data, 

shall be bound by the following assurance.

Assurance of Confidentiality

1. In accordance with all applicable legislation, regulations, and guidelines, AIR assures all 

respondents that their responses may be used only for statistical purposes and may not be 

disclosed, or used, in identifiable form for any other purpose except as required by law 

[Education Sciences Reform Act of 2002 (ESRA 2002), 20 U.S. Code, § 9573].

2. The following safeguards will be implemented to assure that confidentiality is protected as 

allowable by law (20 U.S.C. § 9573) by all employees, consultants, agents, and 

representatives of AIR and all subcontractors and that physical security of the records is 

provided:

a. All staff with access to data will take an oath of nondisclosure and sign an affidavit to 

that effect.

b. At each site where these items are processed or maintained, all confidential records 

that will permit identification of individuals shall be kept in a safe, locked room when 

not in use or personally attended by project staff.

c. When confidential records are not locked, admittance to the room or area in which they 

reside shall be restricted to staff sworn to confidentiality on this project.
d. All electronic data shall be maintained in secure and protected data files, and personally 

identifying information shall be maintained on separate files from statistical data 

collected under this contract.

e. All data files on network or multi-user systems shall be under strict control of a database 

manager with access restricted to project staff sworn to confidentiality, and then only 

on a need-to-know basis.

f. All data files on single-user computers shall be password protected and all such 

machines will be locked and maintained in a locked room when not attended by project 

staff sworn to confidentiality.

g. External electronically stored data files (e.g., tapes on diskettes) shall be maintained in a 

locked storage device in a locked room when not attended by project staff sworn to 

confidentiality.

h. Any data released to the general public shall be appropriately masked such that linkages 

to individually identifying information are protected to avoid individual identification in 

disclosed data.

i. Data or copies of data may not leave the authorized site for any reason.

3. Staff, consultants, agents, or SEDL and all its subcontractors will take all necessary steps to 

ensure that the letter and intent of all applicable legislation, regulations, and guidelines are 

enforced at all times through appropriate qualifications standards for all personnel working 

on this project and through adequate training and periodic follow-up procedures.

By my signature affixed below, I hereby swear and affirm that I have carefully read this 

statement and fully understand the statement as well as legislative and regulatory assurances 

that pertain to the confidential nature of all records to be handled in regard to this project, and 

will adhere to all safeguards that have been developed to provide such confidentiality. As an 

employee, consultant, agent, or representative of SEDL or one of its subcontractors, 

consultants, agents, or representatives, I understand that I am prohibited by law from 

disclosing any such confidential information to anyone other than staff, consultant, agents, or 

representatives of SEDL, its subcontractors, or agents, and Institutes of Education Science. I 

understand that any willful and knowing individual disclosure or allowance of disclosure in 

violation of the applicable legislation, regulations, and guidelines is punishable by law and 

would subject the violator to possible fine or imprisonment.

(Signature) (Date)
AFFIDAVIT OF NONDISCLOSURE

Understanding the Relationship between Implementation of Texas House Bill 5 and Algebra II 

Completion Rates in High Schools

(SEDL under Contract No. ED-IES-12-C-0012)

[insert name]

[insert position]

Date of Assignment to Understanding the Relationship between Implementation of Texas House Bill 5 

and Algebra II Completion Rates in High Schools Study: December 2014

SEDL

4700 Mueller Blvd.

Austin, TX 78723

I, [insert name], do solemnly swear (or affirm) that when given access to any Understanding the 

Relationship between Implementation of Texas House Bill 5 and Algebra II Completion Rates in High 

Schools databases or files containing individually identifiable information, 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 (PL 107-279) and 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 could be 

identified or the data furnished by or related to any particular person under this section 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 5 years [under 18 U.S.C. 3559], or both. The word "swear" should be 

stricken out wherever it appears when a person elects to affirm the affidavit rather than to swear to it.)

State of _____________________________

County of _______________________________

Subscribed and sworn/affirmed before me, ______________________, a Notary Public in and for

________________County, State of ________________________, on this date, 

______________________.

___________________________________________

Notary Public

My commission expires: _____________________________.