CI_Medical_-_Non-Disclosure_Agreement.doc

REQUEST FOR PROPOSALS

TIRNO-13-R-00032

ATTACHMENT 2

NON-DISCLOSURE AGREEMENT

(Awardee and any awardee’s employee under the anticipated contract will be required to complete and provide to the IRS.)

CI Medical Services Conditional Access to Sensitive but Unclassified Information

I_____________, hereby consent to the terms in this Agreement in consideration of my being granted conditional access to certain United States Government documents or material containing sensitive but unclassified information.

I understand and agree to the following terms and conditions:

1. By being granted conditional access to sensitive but unclassified information, the

United States Government has placed special confidence and trust in me and I am obligated to protect this information from unauthorized disclosure, in accordance with the terms of this Agreement.

2. As used in the Agreement, sensitive but unclassified information is any information the loss, misuse, or unauthorized access to or modification of which could adversely affect the national interest or the conduct of Federal programs, or the privacy to which individuals are entitled under Title 5 U.S.C. 522a, but which has not been specifically authorized under criteria established by an Executive Order or an Act of Congress to be kept secret in the interest of national defense or foreign policy.

3. I am being granted conditional access contingent upon my execution of this

Agreement for the sole purpose of ______________. This approval will permit me conditional access to certain information, (documents, reports, maps, drawings, schematics, plans, assessments, etc.) and/or to attend meetings in which such information is discussed or otherwise made available to me.

4. I will never divulge any sensitive but unclassified information that is provided to me pursuant to this Agreement to anyone unless I have been advised in writing by the Internal Revenue Service or in the case of bureau sensitive but unclassified information released to the Office of Inspector General (OIG) or Treasury Inspector General for Tax Administration (TIGTA), in accordance with a written arrangement related to the official audit/investigative functions of the OIG or TIGTA for that particular matter). Should I desire to make use of any sensitive but unclassified information, I will do so in accordance with paragraph 6 of this Agreement. I will submit to the Internal Revenue Service for security review, prior to any submissions for publication, any book, article, column or other written work for general publication that is based upon any knowledge I obtained during the course of my work on (name the project) to ensure that no Internal Revenue Service sensitive but unclassified information is disclosed.

5. I hereby assign to the United States Government all royalties, remunerations, and emoluments that have resulted, will result or may result from any disclosure, publication, or revelation of sensitive but unclassified information not consistent with the terms of this

Section 2 Chapter II Personnel Security Investigations 8 TD P 15-71 Agreement.

6. Upon signing this non-disclosure agreement, I will be permitted access to official

Internal Revenue Service documents containing sensitive but unclassified information and understand that any copies must be protected in the same manner as the originals. Any notes taken during the course of such access must also be protected in the same manner as the originals.

7. If I violate the terms and conditions of this Agreement, I understand that the unauthorized disclosure of sensitive but unclassified information could compromise the Internal Revenue Service security.

8. If I violate the terms and conditions of this Agreement, such violation may result in the cancellation of my conditional access to sensitive but unclassified information. This may serve as a basis for my being denied conditional access to Treasury Department, Internal Revenue Service or other Treasury bureaus’ information, both classified and sensitive but unclassified information in the future. If I violate the terms and conditions of this Agreement, the United States may institute a civil action for damages or any other appropriate relief. The willful disclosure of information to which I have agreed herein not to divulge may constitute a criminal offence.

9. Unless and until I am provided a written release by the Internal Revenue Service from this Agreement or any portions of it, all conditions and obligations contained in this Agreement apply both during my period of conditional access, which shall terminate at the conclusion of my work on _________________/contract (TBD), and at all times thereafter.

10. Each provision of this Agreement is severable. If a court should find any provisions of this Agreement unenforceable, all other provisions shall remain in full force and effect.

11. I understand that the United States Government may seek any remedy available to it to enforce this Agreement, including, but not limited to, application for a court order prohibiting disclosure of information in breach of this Agreement.

12. By granting me conditional access to information in this context, the United States

Government does not waive any statutory or common law evidentiary privileges or protections that it may assert in any administrative or court proceeding to protect any sensitive but unclassified information to which I have been given conditional access under the terms of this Agreement.

13. These restrictions are consistent with and do not supersede, conflict with or otherwise alter the employee obligations, rights or liabilities created by Executive Order 12958, as amended; Section 7211 of Title 5, United States Code (governing disclosures to Congress); Section 1034 of Title 10, United States Code, as amended by the Military Whistleblower Protection Act (governing disclosure to Congress by members of the military); Section 2302(b)(8) of Title 5, United States Code, as amended by the Whistleblower Protection Act (governing disclosures of illegality, waste, fraud, abuse or public health or safety threats); the Intelligence Identities Protection Act of 1982 (50 USC 421 et seq.)(governing disclosures that could expose confidential Government agents), and the statutes that protect against disclosure Chapter II Section 2

Personnel Security Investigations TD P 15-71 9 that may compromise the national security, including Sections 641, 793, 794, 798, and 952 of Title 128, United States Code, and Section 4(b) of the Subversive Activities Act of 1950 (50 USC Section 783 (b)). The definitions, requirements, obligations, rights, sanctions and liabilities created by said Executive Order and listed statutes are incorporated into this Agreement and are controlling.

14. My execution of this Agreement shall not nullify or effect in any manner any other secrecy or nondisclosure Agreement which I have executed or may execute with the United States Government except within the Department of the Treasury as noted in item 8, above.

15. I make this Agreement in good faith, without mental reservation or purpose of evasion.

Name

Date

Signature

This Agreement was accepted by the undersigned on behalf of the Internal Revenue Service as a prior condition on conditional access to sensitive but unclassified information. Further release to any other third party requires execution of a nondisclosure agreement. When information is shared with the Office of Inspector General or the Treasury Inspector General for Tax Administration, for official audit/investigative purposes, the following statement must be added below the signature line. “This Agreement was accepted by the undersigned on behalf of the (identify bureau and (the Office of Inspector General or Treasury Inspector General for Tax Administration, as applicable) for conditional access to sensitive but unclassified information. Further release and dissemination of (identify bureau) sensitive but unclassified information under this non-disclosure agreement must be in accordance with a written arrangement related to the official audit/investigative functions of the OIG or TIGTA for that particular matter. Further release to any other third party requires execution of a nondisclosure agreement.”

(Bureau Signatory)

Date