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Project Director (last name, first initial):_________________________________________________________

If the response to Item E is no, please provide the following:

1. A copy of IRB or other equivalent review board approval of the proposal or

protocol or, if such approval has not been obtained, documentation from

such IRB or equivalent review board as to why such approval is not

required. If the IRB has approved the research proposal or protocol,

please also provide documentation that the IRB has been approved by the

New York State Department of Health and/or the federal government.

2. Copies of at least one, but no more than three, articles you have authored

that were published in peer-reviewed scientific journals. Criteria typically

used for evaluating scientific papers, such as primary authorship, recency

and relevance to the proposed research project, may be considered by the

Board in its evaluation of the researcher’s request for Pesticide Registry

information or pesticide application information.

Please identify, by name, title, responsibility, organization and relationship to

the proposed project, each person designated to obtain and/or have access to

confidential Pesticide Registry information or pesticide application information

(information which contains the name, address or other information that would

identify a commercial or private applicator of pesticides or any person who

receives the services of a commercial applicator). Please attach a list with this

information to this form.

Please attach the specific written plan you will follow to maintain the

confidentiality of confidential pesticide registry information or pesticide

application information. This plan must address the following components of

data security: work area access, PC security, server/network security, and

internet exposure. This must include strict requirements concerning data

accessibility and contain policies regarding both physical and electronic access

including security settings, network connections, and any possible movement of

the data. Provisions shall be made, using current computer security knowledge

and technology, to secure and limit access to confidential information stored on

network computers or computers with an Internet connection.

Your plan must include a diagram of your proposed PC/network infrastructure,

indicating the planned location of confidential information and any proposed

connections to or from any other network or internet resources. The simplest

and most secure environment would be to house the confidential data on a

dedicated stand-alone PC or server in a secure space completely isolated from

any network. Only the investigators would have physical access to the work

area and equipment. Backups would be made and maintained by the

investigators and stored onsite. The backup/recovery plan would have to be

described. Data and printouts would never leave the area. This would offer the

most protection of the data, but could be impractical in carrying out the activities

required.

Your confidentiality plan must be consistent with the following

recommendations:

Request For Pesticide Registry Or Pesticide Application Information - New York State Department Of Health Page 3