University Of Rochester Data Use/transfer Agreement Checklist
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3UNIVERSITY OF ROCHESTER
DATA USE/TRANSFER AGREEMENT CHECKLIST
(Sending Data)
A Data Use/Transfer Agreement (DUA) is a contractual document used for the transfer of data that
has been developed by nonprofit, government or private industry, where the data is nonpublic or is
otherwise subject to some restrictions on its use. Often this data is a necessary component of a
research project and it may or may not be human subject data from a clinical trial, or limited data set
information as defined in HIPAA.
University of Rochester Scientist(s):_________________________________________________
Location: MEDICAL CENTER___ __ RIVER CAMPUS___ _
Date:________________Phone Number(s) ___________________UR BOX # _______________
1) Description of the Data to be transferred (Please list variables to be sent):
RSRB Number: ____________________
Award Number___________________
CTA Number: _____________________
TITLE OF STUDY: ________________________________________________________________
_________________________________________________________________________________
2) Does the Data originate from: Humans ____
Non-human Samples ____
3) Will you be sending de-identified Data**? Yes ______ No _______
**De-identified data is data that does not contain any direct identifiers of the individuals according to
HIPAA.
IF YES - Select one of the following:
___ Data was collected in a de-identified manner approved by the RSRB;
___ Data was collected in an identifiable manner approved by the RSRB
and will be shared in a de-identified manner; or
___ Data was obtained in a de-identified manner with no RSRB approval as it did not meet
the definition of a human subject, or did not meet the definition of research.
Please complete Form 25.5.1 located at:
Upon completion, please forward a copy to the Material Transfer Administrator electronically.
If NO, answer questions below, then continue to page 2 and answer questions 4-7.
Are you sending a Limited Data Set (LDS)? Yes ______ No _______
If YES, please complete Form 25.6.1 located at:
Upon completion, please forward a copy to the Material Transfer Administrator electronically.
Version June 2013
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