Data Use Agreement (DUA) Quarterly Report
Please complete this online form and click on "Submit." If you need to use one or more continuation pages, please submit these pages separately to dhmh.medicaiddatarequests@maryland.gov.
Today's Date *
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Title of Agreement *
Name of Person Completing this Form *
Position Title *
Email Address *
1. Is this Project, which is Under Agreement, Active or Closed? *
2. If Project is Closed, have you submitted a completed Certificate of Study Closure and a completed Certificate of Data Destruction to the Maryland Department of Health? *
If Project is Closed, please use this link: https://mmcp.dhmh.maryland.gov/Pages/Data-Requests.aspx to our Medicaid Data Request website to access the Certificate of Study Closure and the Certificate of Data Destruction forms. Complete these forms and email them to: dhmh.medicaiddatarequests@maryland.gov
3. Briefly describe any analyses or reports utilizing the Medicaid data covered under the DUA that have been started or completed by the research team since the last filed progress report. *
4. Are there any issues and / or changes in the terms of the DUA to report at this time? If "Yes" provide a short description of the issue and/or change where it applies below (see 4a. - 4.i). If "No" skip to question 5. *
4a. Project Manager and/or Agreement Monitor Assignment
4b. Covered Data or Period of Use
4c. Scope of Work
4d. Additional Data Sources
4e. Data Users
4f. Data Management Plan
4g. Data Storage Location
4h. Privacy/Security of Protected Information (e.g., Breach)
4i. Other Issue(s) and/or Change(s)
5. Will the current agreement need to be renewed? *
Other Comments/Concerns:
Type Name of Report Author and Add Date (to serve as your dated signature) *
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