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![]() National Health Interview Survey Current Health Topic Public-use Data Files Order FormDATA USE AGREEMENT - The Public Health Service Act (42 U.S.C. 242m(d)) provides that the data collected by the National Center for Health Statistics (NCHS) may be used only for the purpose for which they were obtained; any effort to determine the identity of any reported cases, or to use the information for any purpose other than for health statistical reporting and analysis, would violate this statutory restriction and the conditions of the data use agreement. NCHS does all it can to ensure that the identity of data subjects cannot be disclosed; as well as characteristics that might lead to identifications are omitted from the data set. Nevertheless, it may be possible in a rare instance, through complex analysis, and with outside information, to ascertain from the data sets the identity of particular persons or establishments. Considerable harm could ensue if this were done. Therefore, the undersigned gives the following assurances with respect to all NCHS data sets:
My signature indicates my agreement to comply with the above-stated statutorily based requirements with the knowledge that deliberately making a false statement in any matter within the jurisdiction of any department or agency of the Federal Government violates 18 U.S.C. 1001 and is punishable by a fine of up to $10,000 or up to 5 years in prison. Signed ____________________________________ Date ___________________________ Print or type name ____________________________________ Title ___________________________ Organization _____________________________________ Telephone (_____)________________ Data tape ordered
_____________________________________ Proposed use
_____________________________________ Density(BPI) : 6250 ____ Format: Tape ____ Cartridge ____ (Default is cartridge) This form can be used for ordering data sets. Indicate the data sets you want, put your name and address below, enclose payment, and send to : Division of Health Interview Statistics Make check payable to: Send indicated data sets to:
_____________________________________ This page last reviewed January 11, 2007
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