UMBC Office of Sponsored Programs (OSP) Submission for the Evaluation of Data Use Agreements (DUA) Incoming
Note: The DUA should normally not be used if a funding agreement (i.e., a subcontract) is in place between UMBC and the other entity for the same project. The funding agreement should address data-sharing. Please consult with your Grants and Contracts Manager to ensure that the appropriate language has been included in the applicable funding agreement. If this DUA relates to current funding, please contact your OSP manager prior to completing this form
Please check only one:
Required
DUA Modification #
University Principal Investigator (PI) Name/Dept.
PI's Department Administrative Contact:
Name of Company/Institution Providing Data:
Company/Institution Contact for Contracts/Legal Issues (Name/Email)
Company/Institution PI Name:
Describe the Data being provided under the DUA.
Describe purpose of the Exchange:
Required
If Other, please describe purpose:
Data required by (Insert date):
MM
/
DD
/
YYYY
Is this human data?
If yes, please upload the IRB approval letter, exemption letter or determination of no human subject involvement
Does the Data contain medical or health information?
Does the information or data relate to substance abuse diagnosis, referral or treatment?
Have all 18 direct identifiers been removed from the data set requested? See 45 C.F.R. 164.514 (b)(2)(i) https://irb.northwestern.edu/sites/irb/files/documents/18hipaaidentifiers.pdf
Does data contain protected health information from medical records? In other words, does data contain any health information that can be used to identify an individual? (This includes, but is not limited to, demographic information or anything related to an individual's past, present, or future health condition and related treatments or payments)?
Please provide additional details/info regarding the data set
Please upload a separate attachment including descriptors, field names, record quantity, etc. Upload attachment
Required
Was this data generated by utilizing data obtained from a 3rd party (under a separate DUA, contract, etc.)?
If yes, please provide name of 3rd party, DUA/contract reference # or details
Will you make a derivative or modification of the data set you receive?
Do you intend to share the results of your research/project back with the provider?
Is there a Data Transferor in addition to a Data Owner? A Data Transferor is the person or entity that has actual possession of and responsibility for the data file.
If yes, please provide contact information for Data Transferor.
Is this data needed for a proposal under development or consideration for funding?
If yes, indicate name of funding agency and please provide Institution numbers, Project numbers or details.
If there are physical storage requirements, please provide details re: locking procedure, workstation to be used, or office security measures:
In what physical locations will the data be used?
Will the data ever be accessed or stored on devices not owned by UMBC?
What software will you use with the data?
Will the data be combined with other data sets? 
Who will be providing computer support for the computers that will be used to access or store this data?
Will removable media (flash drives, CDs, DVDs, etc) be used to store or transport this data?
Who will need to have access to this data (list specific names)?
If there are electronic security standards, please identify your Dept. IT Representative: Name/ Phone/Email:
What is the source of funds you are using to do the research with this data: Please provide Fund/Project number or details.
List all other agreements related to this DUA (i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License, MTA, Other Agreement and provide Institution Number/Project Number or specific details for each):
Submit
Never submit passwords through Google Forms.
This form was created inside of UMBC. - Terms of Service - Additional Terms