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Using Administrative Data To Monitor Access, Identify Disparities, and Assess Performance of the Safety Net

Appendix A. Sample Data Confidentiality Agreement

I, the undersigned, agree to the following:

All data at the individual record level obtained or acquired by the XYZ Center for Health Services Analysis (XYZ Center) shall be treated as strictly confidential and shall not be disclosed or provided to any person who is not an employee of XYZ Center or to any person who has not signed a Data Confidentiality Agreement. In addition:

  1. No attempt shall be made to identify any individual contained in such records.
  2. No aggregate data from such records shall be reported or published with a cell size less than six without written permission of the Executive Director.
  3. All data at the individual record level on computer tape, cartridge, disk, CD-ROM, other computerized storage media, or in hard copy shall be archived in a locked location.
  4. All data at the individual record level on a computer hard drive shall be password protected.
  5. Any breach or suspected breach of data confidentiality shall be reported immediately to the Executive Director.

Any intentional violation of this agreement shall be the basis for dismissal for cause.

_____________________________
(Signature)

______________
Date

_____________________________
(Print Name)


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