Non-Disclosure and Confidentiality Certification Form



Non-Disclosure and Confidentiality Certification FormThe undersigned understands that, as a subrecipient of the University of South Florida’s Home Instruction for Parents of Preschool Youngsters (HIPPY) grant sponsored by the Florida Office of Early Learning, he/she will or may be exposed to certain confidential information pertaining to OEL programs. By signing the Non-Disclosure and Confidentiality Certification form, the individual acknowledges that any privileged data or material to which he/she has access or gains access as a result of the information being made available to his/her employer, is intended for the limited purpose of performing the entity’s contractual duties pursuant to Contract SR936. These confidential records may include, but are not necessarily limited to, personal identifying information of program applicants, recipients, or participants such as names, social security numbers, payment information, the name of the child care provider, household demographics, the name of an employer, resource and referral information, and records of children in the Voluntary Prekindergarten and School Readiness programs which are private and confidential and may not be disclosed to others. The undersigned will receive access to approved usernames, passwords, and additional instructions for accessing the early learning information technology systems and programs (hereinafter referred to as “the Systems”) and may receive confidential unemployment information in the performance of his/her official duties. Prior to receiving such access, the undersigned acknowledges and agrees to abide by the following standards for the receipt and handling of confidential record information.The undersigned shall not disclose any usernames, password or other information needed to access the Systems to anyone.If the undersigned suspects that any unauthorized person may have obtained or has obtained access to any username, password or other information needed to access the Systems, the undersigned shall immediately notify the appropriate person, as designated by his/her employer.Unless collection of social security numbers or other confidential information is necessary for the performance of the individual’s official duties, the undersigned shall not access or request access to any privileged information.The undersigned shall not disclose any individual record data or confidential information to anyone who is not authorized to receive such data except in the form of reports containing only aggregate statistical information compiled in such a manner that it cannot be used to identify the individual(s) involved. For example, if cell sizes include information for a minimum of 10 individuals, this would qualify as aggregate statistical information.The undersigned shall retain confidential data only for that period of time necessary to perform its duties. Thereafter, the undersigned shall either arrange for the retention of such information consistent with both the federal or state record retention requirements or delete or destroy such data. Unless such information is required to be retained pursuant to state or federal law, the undersigned agrees to destroy any confidential information obtained, and any copies thereof made by the undersigned after the purpose for which the information was provided in such a way to ensure the deletion of personal identifiers to prevent the information from being reconstructed by any means. Information stored on routine back-up media for the purpose of disaster recovery will be subject to destruction in due course.? Latent data such as deleted files and other non-logical data types, such as memory dumps, swap files, temporary files, printer spool files and metadata that can customarily only be retrieved by computer forensics experts and are generally considered inaccessible without the use of specialized tools and techniques will not be within the requirements set forth by this paragraph. Some data maybe retained beyond the minimum retention requirements of state or federal law. This data will be managed to meet OEL needs and deleted upon request. The undersigned understands any confidential information shall only be used for the purposes authorized in the contract, or by law, or by legal process.The undersigned understands any confidential information must be stored and processed in such a way that unauthorized persons cannot view or obtain the information by any means.The undersigned acknowledges that he/she must take precautions to ensure that only authorized persons are given access to disclosed confidential information stored in the Systems.The undersigned acknowledges he/she has received training, written standards, or instructions on the proper use, handling, storage and destruction of confidential data and the sanctions for violations from his/her employer. The undersigned agrees to comply with all the confidential safeguards contained in such training, written standards, or instructions, including but not limited to, the following: a) protecting the confidentiality of usernames and passwords; b) securing computer equipment, disks, and Offices in which confidential data may be kept; and c) following procedures for the timely destruction or deletion of confidential data.The undersigned understands that pursuant to sections 1002.72 and 1002.97, F.S., the records of children in the Voluntary Prekindergarten and School Readiness programs are confidential and exempt from public disclosure.The undersigned acknowledges and understands that anyone who violates any of the confidentiality provisions set forth in the training, written standards, and/or instructions, will have his/her user privileges immediately suspended or terminated and could face criminal charges pursuant to section 775.082 or 775.083, F.S., if convicted. The undersigned has been instructed that if he/she violates the provisions of the law, one or more of these penalties may be imposed. The undersigned shall permit OEL to make on-site inspections of records relevant to this Contract to ensure that the requirements of the state and federal law and regulations are being met. Such inspection may take place with or without notice at any time during normal business hours. The undersigned shall maintain a filing system sufficient to permit an audit by OEL or its agent of their compliance with this Contract.The undersigned agrees not to store or allow anyone to store any confidential information on any unencrypted portable storage media (e.g., laptops, thumb drives, etc.).By signature below, I acknowledge that I have been instructed on the confidentiality requirements and sanctions stated above and will adhere to the identified requirements and procedures and will report any infraction or suspected infraction of this Contract to the appropriate person, as designated by my employer.Signature: _____________________Date: _____________Print Name: ___________________Print Employer Name:___________________Address: ___________________ ___________________Work Telephone: ______________________E-Mail: _____________________ ................
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