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 Yes, if yes attach informed consent document. Informed Consent? No 3. If data was NOT collected under Yes, if yes attach the waiver of informed consent document. informed consent, did the IRB No approve a waiver of Informed Consent? 4. If data was NOT collected under Is the data identifiable? Yes informed consent AND the IRB did No NOT approve a waiver of informed Is the data a Limited Data Set (LDS)? Yes consent, then: No If yes, check the applicable fields that will be provided: Dates Zip Codes 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 Funding Source: collect the data: 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 Yes agreements/funding/materials No applicable to your research (consider all that apply, i.e., If yes - Sponsored Research Agreement, Please list the agreements: Government or Other Grant, CDA, Institution Number: License, MTA, Subcontract, Other Project Details: Agreement)? Does this agreement address data sharing with this recipient? Yes. If yes, please explain: No Recipient Information (Sending) 1. Do you require reimbursement for Yes. If yes, please explain: the cost to provide the data? No 2. Do you require the recipient to Yes. If yes, please explain: collaborate, share results or No anticipate that they will jointly publish with you? Restrictions Information (Sending)
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, if yes attach informed consent document. No 3. If data was NOT collected under informed consent, did the IRB approve a waiver of Informed Consent? Yes, if yes attach the waiver of informed consent document. No 4. If data was NOT collected under informed consent AND the IRB did NOT approve a waiver of informed consent, then: Is the data identifiable? Yes No Is the data a Limited Data Set (LDS)? Yes No If yes, check the applicable fields that will be provided: Dates Zip Codes 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)
DUA%20Submission%20Form%20-%20LEGACY%20-%20091514.docx