OCRC Data Transfer Intake Form (DTIF)

External Party Name (“Recipient”):
Form Completed By:
Form submitted to OCRC by:

THIS FORM ONLY NEED TO BE FILLED OUT IF HUMAN SUBJECTS RESEARCH DATAOR SAMPLES ARE BEING TRANSFERRED* TO OR RECEIVED FROM DUKE. *ACCESS TO DATA IS THE SAME AS TRANSFERRING OR RECEIVING DATA.

  1. Data will be transferred from (Discloser) to (Recipient).

Check here if data will flow both ways(i.e., to and from each party(ies)).

  1. If Duke is the Discloser, Duke’s source of data isstandard of care or research study.

If a research study, provide name of PI: ; StudyName: ; eIRB#: Pro000; Research study’s source of funding; SPS#.

  1. If Duke is Recipient and data will be used for a research study please provide PI Name: ; Study Name: ; eIRB#: Pro000; research study’s source of funding ; SPS# .
  1. Recipient will use data for Registry, Business Operations or Research Study.

If a research study, provide name ofPI: and studyname

  1. Discloser will provide data to Recipient via: Access credentials to file server; Duke Box (Duke IRB prefers the use of Duke Box when possible); REDCAP; other Internet file transfer system; Physical digital media, such as flash drive or hard drive; Physical printed media, such as paper binder
  1. Please checkall HIPAA identifiers listed below that will be disclosed:

Names

Geographic designation, other than country or state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes; will ZIP Codes, in whole or in part, be provided?

Yes; No

All elements of dates (except year alone) directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older

Telephone numbers

Facsimile numbers

Electronic mail addresses

Social security numbers

Medical record numbers

Health plan beneficiary numbers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers, including license plate numbers

Device identifiers and serial numbers

Web universal resource locators (URLs)

Internet protocol (IP) address numbers

Biometric identifiers, including fingerprints and voiceprints

Full-face photographic images and any comparable images

Any other unique identifying number, characteristic or code; indicate whetherRecipient will have access

to key to re-identify data using such other unique identifier(s): Yes; No

  1. Provide brief scope of work and description of data flow, including source of data, what data will be transferred by Discloser,how data will be disclosed to Recipient, and how Recipient will use the data.
  1. Does thetransfer include samples? Yes; No.

Ifyes, are the samples de-identified?Yes; No

  1. Does the transfer involve genetic data? Yes; No.

If yes, describe:

  1. Does the applicableDiscloser ICF allow disclosure of the data to Recipient? Yes; No

Does the applicable Discloser ICF allow use of the data by Recipient? Yes; No

Comments, if any:

  1. Will payment be exchanged in connection with data transfer or use? Yes; No.

If so, describe:

  1. Contract under which Discloser will disclose data to Recipient:

RSSA/OSA, sub-agreement, DTA, DUA, don’t know

other (describe):

  1. Will mobile Apps be used to collect, store or transfer the data? Yes; No.

If yes, describe:

  1. Will Recipient have remote access to any Duke systems? Yes; No.

If yes, describe:

  1. Does Discloser want publication rights regarding disclosure or use of data? Yes; No.

If yes, describe: