Data Confidentiality And Security Agreement Form printable pdf download

Confidential Data Request Application

Data Confidentiality and Security Agreement Form

All principal and secondary investigators who will have access to the confidential data requested in the Confidential

Data Request Application must sign this form and submit it with the Application.

I _____________________________________, as a principal or secondary investigator, agree to receive

confidential data from the Michigan Department of Education (MDE) and/or the Center for Educational

Performance and Information (CEPI), and to observe the following security provisions in transferring, storing,

analyzing and reporting of the data.

1. Policy for data storage

a. The location of all copies of the data must be carefully tracked

b. The data must be stored where only the Confidential Data Request Application designed principal and

secondary investigator(s) may access the data

c. Data files must remain secure throughout the duration of data storage

2. Policy for data usage

a. Data may be accessed only by the Confidential Data Request Application designed principal and secondary

investigator(s)

b. Data may not be shared with any other individuals outside those designed as the principal and secondary

investigator(s) in the Confidential Data Request Application

c. Data may be used only for analyses that respect privacy and confidentiality of all concerned parties

including students, teachers, classrooms, schools, districts, intermediate school districts and the State of

Michigan

d. Data may only be used for the purposes of answering the research questions and/or hypotheses presented in

the Confidential Data Request Application

e. Publically available discussions, presentations and reports based upon the confidential data may not include

information that would make it possible to identify a student, teacher, classroom, school, district,

intermediate school district or the State of Michigan unless specific permission has been granted in writing

to do so

Internal discussions and reports should protect the privacy, anonymity and confidentiality of all concerned

parties if there is any reasonable possibility that the internal document may become publically available

g. Internal documents that contain any identifying information must clearly be marked "confidential—for

internal use only"

h. Data will, at all times, adhere to the Family Educational Rights and Privacy Act (FERPA).

3. Policy for data disposal

a. The data must be destroyed in accordance with the date designated for destruction in the signed

Confidential Data Request Application

b. If an extension on the data destruction deadline is needed, the Research Collaborative Internal Review

Board must be contacted, in writing, to approve an extension

c. A certificate of destruction will be sent via US mail to the Research Collaborative Internal Review Board

on the date of the data loan expiration

______________________________________

______________________________________________

________________

Signature of Investigator

E-mail and Phone Number

Date

Confidential Data Request Application

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Data Confidentiality And Security Agreement Form

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