Fillable Privacy Certificate to a private person2 will not (U.S. Department of Justice, Office of Justice Prograns)

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Privacy Certificate to a private person2 will not (U.S. Department of Justice, Office of Justice Prograns)

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Privacy Certificate
Grantee1, _____________________________________________, certifies that data identifiable
to a private person2 will not be used or revealed, except as authorized in 28 CFR Part 22,
Sections 22.21 & 22.22.
Brief Description of Project (required by 28 CFR §22.23(b):
Grantee certifies that any private person from whom identifiable information is collected or
obtained shall be notified, in accordance with 28 CFR §22.27, that such data will only be used or
revealed for research or statistical purposes and that compliance with the request for information
is not mandatory and participation in the project maybe terminated at any time. In addition,
grantee certifies that where findings in a project cannot, by virtue of sample size or uniqueness
of subject, be expected to totally conceal the identity of an individual, such individual shall be so
advised.
Procedures to notify subjects that such data will only be used or revealed for research or
statistical purposes and that compliance with the request for information is not mandatory
and participation in the project maybe terminated at any time as required by 28 CFR
§22.23(b)(4):
If notification of subjects is to be waived, pursuant to 28 CFR §22.27(c), please provide a
justification:
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please enter it on the blank pages at the end of this form or attach a separate sheet.
NOTE: If no data identifiable to a private person will be collected, this form is considered complete
following insertion of the project description and the phrase "No data identifiable to a private person will be
collected here." All other blanks should have inserted “Not applicable since this study is not collecting
identifiable data”. The form must then be signed and dated.
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field, please enter it on the blank pages at the end of this form or attach a separate sheet.
NOTE: Informed consent procedures and forms as approved by the IRB should be
attached.
Grantee certifies that project plans will be designed to preserve the confidentiality of private
persons to whom information relates, including where appropriate, name-stripping, coding of
data, or other similar procedures.
Procedures developed to preserve the confidentiality of personally identifiable information,
as required by 28 CFR §22.23(b)(7):
Grantee certifies that, if applicable, a log will be maintained indicating that (1) identifiable data
have been transferred to persons other than employees of NIJ, BJA, BJS, OJJDP, OVC, OJP, or
grantee/contractor/subcontractor staff; and (2) such data have been returned or that alternative
arrangements have been agreed upon for future maintenance of such data, in accordance with 28
CFR §22.23(b)(6).
Justification for the collection and/or maintenance of any data in identifiable form, if
applicable:
Procedures for data storage, as required by 28 CFR §22.23(b)(5):
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please enter it on the blank pages at the end of this form or attach a separate sheet.
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please enter it on the blank pages at the end of this form or attach a separate sheet.
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field, please enter it on the blank pages at the end of this form or attach a separate sheet.
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field, please enter it on the blank pages at the end of this form or attach a separate sheet.
Grantee certifies that all contractors, subcontractors, and consultants requiring access to
identifiable data will agree, through conditions in their subcontract or consultant agreement, to
comply with the requirements of 28 CFR §22.24, regarding information transfer agreements.
Grantee also certifies that NIJ will be provided with copies of any and all transfer agreements
before they are executed as well as the name and title of the individual(s) with the authority to
transfer data..
Description of any institutional limitations or restrictions on the transfer of data in
identifiable form, if applicable:
Name and title of individual with the authority to transfer data:
___________________________________________________________________
Grantee certifies that access to the data will be limited to those employees having a need for such
data and that such employees shall be advised of and agree in writing to comply with the
regulations in 28 CFR Part 22.
Grantee certifies that all project personnel, including subcontractors, have been advised of and
have agreed, in writing, to comply with all procedures to protect privacy and the confidentiality
of personally identifiable information.
Access to data is restricted to the following individuals, as required by 28 CFR
§22.23(b)(2):
Principal Investigator(s)
Project Staff
Contractors, Subcontractors, and/or consultants
Grantee certifies that adequate precautions will be taken to ensure administrative and physical
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please enter it on the blank pages at the end of this form or attach a separate sheet.
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please enter it on the blank pages at the end of this form or attach a separate sheet.
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this field, please enter it on the blank pages at the end of this form or attach a
separate sheet.
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security of identifiable data and to preserve the confidentiality of the personally identifiable
information.
Procedures to insure the physical and administrative security of data, as required by 28
CFR §22.25(b), including, if applicable, a description of those procedures used to secure a
name index :
Procedures for the final disposition of data, as required by 28 CFR §22.25:
Name and title of individual authorized to determine the final disposition of data:
Grantee certifies that copies of all questionnaires, informed consent forms and informed consent
procedures designed for use in the project are attached to this Privacy Certificate.
Grantee certifies that project findings and reports prepared for dissemination will not contain
information which can reasonably be expected to be identifiable to a private person, except as
authorized by 28 CFR §22.22.
Grantee certifies that the procedures described above are correct and shall be carried out.
Grantee certifies that the project will be conducted in accordance with all the requirements of the
Omnibus Crime Control and Safe Streets Act of 1968 as amended and the regulations contained
in 28 CFR Part 22.
Grantee certifies that NIJ shall be notified of any material change in any of the information
provided in this Privacy Certificate.
Signature (s):
____________________________________ (Principal Investigator)
____________________________________ (Principal Investigator)
____________________________________ (Institutional Representative)
Date:____________________________
Notes:
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field, please enter it on the blank pages at the end of this form or attach a separate
sheet..
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field, please enter it on the blank pages at the end of this form or attach a separate sheet.
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field, please enter it on the blank pages at the end of this form or attach a separate
sheet.
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1 Please include the name of the Principal Investigator(s) for this project as well as the name of
the person representing the institution receiving the grant funds.
2 Information identifiable to a private person is defined in 28 CFR §22.2(e) as "information
which either--(1) Is labeled by name or other personal identifiers, or (2) Can, by virtue of sample
size or other factors, be reasonably interpreted as referring to a particular person."
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Privacy Certificate to a private person2 will not (U.S. Department of Justice, Office of Justice Prograns)

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Completed 7 August 2020

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