Get Cdc Designated Agent Form

Filling out the Cdc Designated Agent Form online is an important step for researchers seeking designated agent status. This guide will provide clear, step-by-step instructions to help you successfully complete the form.

Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to acquire the form and open it in your chosen editor.
2. In Part A, provide your full name in the specified order: Last, First, and Middle. Include your date of birth in the MM/DD/YYYY format, and your Social Security Number. Indicate your citizenship status by selecting 'Yes' or 'No' and, if applicable, specify your country of citizenship. Enter your local home address, including street, city, state, and zipcode. If your legal address differs from your home address, fill that in as well. Additionally, provide your home phone number, cell phone number, employer name, supervisor's name, work address, work number, and supervisor's number.
3. In Part B, state your reason for being present at NCHS by entering the title of your project as indicated in the approved project proposal. Below, list up to 5 keywords that describe your project. Specify the time period in which you expect to conduct work in the NCHS RDC by providing both a start date and an end date in the appropriate format.
4. In Part C, complete the Affidavit of Non-Disclosure section by writing your name where indicated. Acknowledge your commitment to observe all confidentiality policies and procedures, and ensure you do not disclose any confidential information during or after your tenure as an agent. Sign your name in the designated area.
5. Have the oath of non-disclosure administered by a person authorized per the specified regulations. This requires the printed name and signature of the notary public or supervising officer, along with the expiration date of their commission.
6. Finally, save your changes to the form. You can then download, print, or share the completed document as necessary.

Complete your Cdc Designated Agent Form online to ensure a smooth application process.