Office for Sponsored Research Chicago Campus

DATA USE AGREEMENT (DUA)
INBOUND REQUEST FORM

Shading appears on the screen to identify the fields.
This shading does not print. / This form should be used when an NU investigator is receiving a dataset from another organization. To request that an Inbound DUA be processed, please complete this form and email it to along with the Provider’s DUA. Questions, call 312-503-0884 or 312-503-3897.
NORTHWESTERN PRINCIPAL INVESTIGATOR INFORMATION
PI NAME
PHONE / EMAIL
If Contact Person is different than PI,
CONTACT NAME: / CONTACT PHONE/EMAIL:
ABOUT THE DATA SET BEING REQUESTED
DESCRIBE DATA SET (e.g.: EEG data from patients with Alzheimer’s, Cook County traffic pattern data, etc.)
Is the data related to human subjects? YES NO
PROVIDING INSTITUTION OR COMPANY NAME
CONTACT NAME / CONTACT EMAIL
DESCRIBE THE NATURE OF THE DATA SET (IF RELATED TO HUMAN SUBJECTS):
Completely de-identified data (i.e. includes no personal identifiers)
Limited Data Set (as defined by HIPAA, i.e. data contains some amount of identifying information, but
excludes specified direct identifiers)
Protected Health Information (as defined by HIPAA, i.e. includes specific, identifying patient information)
* If PHI, please attach a copy of your IRB approval letter which covers your use of the inbound PHI
If you’re unsure which description applies to the data being transferred, please consult with NU’s IRB.
DATA SHARING
Will you be sharing the data with any outside (non-Northwestern) third parties? YES NO
If yes, please describe how the data will be disclosed and to whom:
SPECIFY FUNDING SOURCE(S) FOR THE PLANNED EXPERIMENTS USING THIS DATA
Industry. Please provide Sponsor Name(s) here:
Federal Grant(s). Federal agency:

Non-federal Grant(s). Grantor Name(s):

Gift Funds. Giver Name(s):

Other. Please describe:

THIRD PARTY COMMITMENTS
Please identify any existing commitments made to third parties regarding this research project and the transfer of data which are not already disclosed above:
CONFIDENTIAL INFORMATION
Will you need to receive any confidential information from the Provider about this Data? YES NO

Please submit:

(1) this form,

(2) the Provider’s DUA, if they sent one to you,

(3) a brief description of your research for which the requested data will be used, and

(4) any correspondence you received from the Provider regarding their DUA to

The DUA will be reviewed for compliance with Northwestern policies. If the DUA is acceptable, OSR will sign and send it to the Provider. If not, OSR will negotiate the DUA terms with the Provider. Once the DUA has been signed by all parties, a copy will be sent to the PI as a record of the transaction and to refer to throughout the research project.

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