Attachment 3 NON DISCL.pdf

Attachment 3 – FDA Non-Disclosure Form

(NOTE: To be completed by prospective Offeror if access to sensitive information, non-public information, confidential information, and/or Controlled Unclassified Information (CUI) is required in order to prepare an offer.)

Information and Information Technology Systems Security Non-Disclosure Agreement (NDA) Request For Proposal (RFP) No: (Fill in the RFP Number)

Project Title: (Fill in Title from RFP)

(Organization’s name), intends to respond to the Government’s Solicitation/Project title indicated above. The Government has determined that the solicitation requires prospective Offerors to have access to sensitive information in order to prepare an offer.

I, (Offeror Official name and title), of (Organization’s name), on this day of , 20 , on behalf of my organization hereby request access to the sensitive information described in Section L.III. of the RFP cited above.

I, the undersigned, understand that the Government has determined that any individual having access to the sensitive information described in the RFP must possess a valid and current Suitability Determination at the Level identified in Section L.III. of the RFP cited above.

I, the undersigned, do hereby affirm the following:

• I have a valid and current Suitability Determination sufficient to access the sensitive information (copy of suitability determination attached).

• I will be the corporate official solely responsible for appropriately safeguarding the sensitive information while in the possession of (Organization’s name);

• The sensitive information will be used solely for the purpose of preparing an offer;

• I will not release, publish, or disclose the sensitive information to unauthorized personnel; and

• I will protect the sensitive information and personally identifiable information in accordance with relevant federal laws, regulations and guidelines.

Signature of Prospective Offeror:

Name of Prospective Offeror:

Date:

Signature of Witness:

Name of Witness:

Date:

Copies Retained by: Contractor Official and Contracting Officer

Attachment 3 – FDA Non-Disclosure Form

• Information Technology Systems Security Contractor Non-Disclosure Agreement

Access to sensitive information (such as personally identifiable information [PII]), non-public information, confidential information, and/or Controlled Unclassified Information (CUI) from the files of the Food and Drug Administration is required in the performance of my official duties, under contract number ______________between (FDA I/C Name or Component) and my employer (Employer’s Name)_____________________ . I agree that I shall not release, publish, or disclose such information to unauthorized personnel, and I shall protect such information in accordance with relevant federal laws, regulations, and guidelines.

I shall protect such information in accordance with the provisions of 21 U.C.S. 331 (j), 21 U.C.S.

360j(c), 18 U.C.S. 1905 and other pertinent laws and regulations governing the confidentiality of non-public information.

I understand the provisions of 21 U.C.S. 331 (j), 21 U.C.S. 360j(c), 18 U.C.S. 1905 and that I am subject to criminal penalties prescribed by law for any violation(s) thereof.

I affirm that I have received a written and/or verbal briefing by my company concerning my responsibilities under this agreement. I understand that violation of this agreement may subject me to criminal and civil penalties.

Signed:

Type or Print Name:

Date:

Witnessed by:

Date:

Copies are to be retained by: FDA Contracting Officer Representative Contractor’s Contract Management Individual Signatory