Pitt Principal Investigator Will Be SENDING Data (Complete Sections Labeled Sending Below)

INTERNAL SUBMISSION FORM FOR THE REVIEW OF DATA USE AGREEMENTS (DUA)

Basic Information

1. / Principal Investigator:
2. / Department/Institute/Center that will be administratively responsible for this Agreement: / Department/Institute/Center Name:
Department/Institute/Center ID:
3. / Is the draft of the agreement attached? / Yes, Draft agreement attached
No, Pitt to Generate First Draft
No, this is an Addgene Order
No, this is an NCI dbGaP Study
No this is an NCI Development Therapeutics Study
Other, please explain:
4. / Title of Submission:
5. / Department Administrative Contact: / Name:
E-Mail:

Contracting Party Information

1 / Contracting Party Name:
2. / Legal Contact Name:
3. / Legal Contact E-Mail Address:
4. / Legal Contact Phone Number:
5. / Scientific Contact Name:
6. / Scientific Contact E-mail:
7. / Does the Principal Investigator have a financial relationship with any of the Contracting Parties listed above that is or should be disclosed on your University of Pittsburgh Conflict of Interest disclosure form? / Yes
No
If Yes, please explain:

Pitt Principal Investigator will be SENDING data (complete sections labeled “Sending” below)

Pitt Principal Investigator will be RECEIVING data (complete sections labeled “Receiving” below):

If Pitt Principal Investigator will be both SENDING and RECEIVING data please complete both sections.

Data Information (Sending)

1. / Description of data:
2. / Purpose of sending the data:

Compliance Information (Sending)

1. / What is the origin of this data? / Animal
Student (or Educational)
Human Subject Research, attach IRB approval letter
Other. If other, explain:

Human Subject Research Information (Sending)

1. / Attach IRB Approval Letter
2. / Was the data collected under Informed Consent? / Yes
No
3. / Is the data identifiable? / Yes, if yes, please explain:
No
4. / Is the data a Limited Data Set (LDS)? / Yes
No
If yes, check the applicable fields that will be provided:
Dates
Zip Codes
Other, please explain:

Funding Information (Sending)

1. / Is the source of funding: / Internal (e.g. departmental or start-up funding)
External (e.g. sponsored research)
2. / Indicate the funding source used to collect the data: / Funding Source:
Grant Identifier/Award #:
PI of Grant Funds:
Are Funds Housed a Pitt? Yes No
If no, where are funds housed?
3. / Are there any other agreements/funding/materials applicable to your research (consider all that apply, i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License,MTA, Subcontract, Other Agreement)? / Yes
No
If yes -
Please list the agreements:
Institution Number:
Project Details:
Does this agreement address data sharing with this recipient?
Yes. If yes, please explain:
No

Recipient Information (Sending)

1. / Do you require reimbursement for the cost to provide the data? / Yes. If yes, please explain:
No
2. / Do you require the recipient to collaborate, share results or anticipate that they will jointly publish with you? / Yes. If yes, please explain:
No

Restrictions Information (Sending)

1. / Are you aware of any restrictions or confidentiality obligations that would impact sharing of this data? / Yes. If yes, please explain:
No
2. / Is the data under disclosure to or patented by Pitt Office of Technology Management (OTM)? / Yes
No
If yes:
OTM Staff:
OTM Case Number:

Data Information (Receiving)

1. / Description of data:
2. / Purpose of sending the data:

Compliance Information (Receiving)

1. / What is the origin of this data? / Animal
Student (or Educational)
Human Subject Research
Other. If other, explain:

Human Origin Information (Receiving)

Funding Information (Receiving)

Data Use Information (Receiving)

1. / Will you make a derivative or modification of the received data? / Yes. If yes, please explain:
No
2. / Do you intend to collaborate, share results or anticipate that you will jointly publish with the sender? / Yes. If yes, please explain:
No
3. / Do you intend to share this data with non-Pitt persons? / Yes. If yes, please explain:
No
If yes, What data will you share?
Received Data
Modified Data

Restrictions Information (Receiving)

1. / Are you aware of any restrictions or confidentiality obligations that relate to hardware, software or office security? / Yes. If yes, please explain:
No
2. / Does the data need to be stored and managed per any cited electronic security standards? / Yes
No
If yes, provide -
Department IT staff name:
Department IT staff e-mail:

Additional Information

1. / Additional information relevant to the review of this request, including any time constraints: