Model Privacy Certificate
THIS MODEL PRIVACY CERTIFICATE IS FOR USE BY APPLICANTS SEEKING NIJ FUNDING. IT IS A STAND-ALONE DOCUMENT. ALL SECTIONS SHOULD BE COMPLETED. PLEASE PREPARE ON LETTERHEAD AND DELETE THIS HEADING.
Printer-friendly, fillable version of this model privacy certificate (pdf, 11 pages).
Grantee, _____________________________________________, certifies that data identifiable to a private person 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):
[NOTE: If no data identifiable to a private person will be collected, this form is considered complete following insertion of the phrase " No data identifiable to a private person will be collected" here along with a brief description of the project. All other blanks should have inserted " Not applicable since this study is not collecting identifiable data." The form must then be signed and dated.]
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 may be 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):
[NOTE: Informed consent procedures and forms as approved by the IRB should be attached.]
If notification of subjects is to be waived, pursuant to 28 CFR §22.27(c), please provide a justification:
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):
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 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)
 Please include the name of the Principal Investigator(s) for this project as well as the name of the grantee organization on line 1. In the signature blocks, the PI(s) should sign, as well as the person representing the institution receiving the grant funds. Where a research project involves human subjects, the chair of the Institutional Review Board (IRB) should sign as authorizing official.
 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."
Date Created: November 20, 2007