UMBC Office of Sponsored Programs (OSP) Submission for the Evaluation of Data Use Agreements (DUA) Outgoing
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? 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)? *
Does the informed consent allow for sharing of data?
If yes, please upload the informed consent document
Please provide additional details/info regarding the data set.
Please upload a separate attachment including descriptors, field names, record quantity, etc. Upload attachment *
Required
Do you require the recipient PI to share results back with you? *
Is this a collaboration with the recipient?
Was this data collected with the use of federal funds?
If yes, please provide institution numbers, project numbers or details:
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
Do you have any other requirements for the exchange? *
If yes, specify
Are you aware of any restrictions or confidentiality obligations that would impact sharing this data? *
If yes, specify
Is the Data under review by OTD?
If yes, with whom are you working?
Is there a cost for you to provide data? Costs charged must total exact costs spent to provide data.
If yes, please explain
Shipping only - via recipient entity; FedEx account
No cost
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):
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