Office of Research Affairs: Data Use Agreement

Office of Research Affairs: Data Use Agreement

To request a Data Use Agreement, please fill out all fields below.

PI INFORMATION

PI First Name

PI Last Name

PI Department

PI Email

DEPARTMENT PRIMARY CONTACT PERSON INFORMATION

Contact First Name

Contact Last Name

Contact Email

OTHER PARTY INFORMATION (INSTITUTION/PARTY SENDING OR RECEIVING DATA)

Other Party Name

Other Party Contact Name

Other Party Street Address

Other Party City

Other Party State

Other Party ZIP/Postal Code

Other Party Country

Other Party Contact Email

STUDY INFORMATION

Data Flow

Incoming DataOutgoing DataBoth incoming and outgoing data

Project Title

Funding Source of the Project

Sponsored ResearchInternal Funding

Sponsor Name

OSP Number

Purpose/Scope of Work

Was data collected under informed consent?

YesNo

Data Is:

De-identifiedLimited Data SetProtected Health InformationSee FDP Guidance regarding types of Data.

If Limited Data Set, Data Includes:

DatesZIP CodesOther

Data points to be shared:

IRB Approval:

YesPendingExempt / Non-human subjects determinationPI certifies that data is de-identified and no IRB submission is necessary

Study Number:

Is data being sent out of the United States?

YesNo

Is any material being shared pursuant to this study?

YesNo

If Yes: provide CMI Contact:

Are there any other agreements related to this study?

YesNo

Provide OSP or Record Number:

Provide Details on the Additional Agreement(s):

Is there any payment associated with the data sharing?

YesNo

Form of Agreement

Upload PDF or Word version of DUA provided by other partyPenn State to draft DUA

Upload the Data Use Agreement received from the other party:

Additional Comments: