OSP Data Use Agreement

HSC Faculty Information

Your Name*

First Last

Your Title*

Your Department*

Other Department*

Your Phone*

Your Email*

Your Departmental Admin Contact (if applicable)

External Party Information

Entity Name*

Entity Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Scientific Contact Name*

First Last

Scientific Contact Email*

Administrative Contact Name*

First Last

Administrative Contact Email*

Administrative Contact Phone

Information About the Data

Please review the data classification tool with the link below. This data is:*

Data Classification Tool

[Check all that apply]

Personally Identifiable Information (PII)
Personal Health Information (PHI)
Limited Data Set as defined in 45 CFR 164.514(e)
De-Identified Data

Please provide a brief description of the data.*

Please provide one of the following:*

IRB Protocol Number for use of the data:
Attach IRB letter, exemption letter or determination letter:

IRB Protocol Number for use of the data:*

Attach IRB letter, exemption letter or determination letter:*

Max. file size: 22 MB.

Maximum allowed file size: 9.76MB

Will HSC provide or receive data?*

Provide
Receive
Both

HSC Providing Data

Was this data generated or collected by HSC?*

Yes
No

Was the data generated or collected, or will it be generated or collected, as part of an HSC Sponsored Project?*

Yes
No

Please provide the ProjID(s) associated with the project(s)?*

Please explain the origin of the data and any known restrictions on the data’s use:*

Do you want to require the receiving party to include acknowledgements in any publications resulting from use of the data set?*

Yes
No

How would you like the acknowledgement worded?*

Would you like an opportunity for pre-publication review of publications resulting from use of the data set?*

Yes
No

Would you like to receive copies of any publications resulting from use of the data set?*

Yes
No

Please explain any additional restrictions on the use of the data that you would like to request (e.g. specific users only, special security/encryption requirements, limitations on how the data can be used, etc.).

HSC Receiving Data

Will the data be shared with any outside (non-HSC) parties?*

Yes
No

Please identify the parties:*

Will the data be accessed by anyone at HSC other than the PI?*

Yes
No

Please identify the individuals or groups accessing the data:*

Has the other party provided a template DUA for review?*

Yes
No

Please attach a copy of the template provided:*

Max. file size: 22 MB.

OSP Data Use Agreement

HSC Faculty Information

External Party Information

Information About the Data

HSC Providing Data

HSC Receiving Data

Quick links

Resources

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OSP Data Use Agreement

HSC Faculty Information

External Party Information

Information About the Data

HSC Providing Data

HSC Receiving Data

Quick links

Resources

Connect with us

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