JROC - DUA Intake Form

This form is for internal use only. Please do not forward to external parties.

This survey does not automatically save.

Do not refresh the page or close this tab/web browser without saving the survey.

Please use this survey to provide information about the proposed data transfer. If there are additional attachments you would like to provide us please use the extra upload spaces provided at the bottom of the survey.

HOW TO SAVE AND RETURN TO THE SURVEY: You may pause this survey at any time by scrolling to the bottom of the page and clicking "Save & Return Later." Enter your email on the following page, and click "Send Survey Link." Redcap will send you an e-mail containing a link that will allow you to access and finish the survey at a future time. Be carful not to lose this link as you may have to start over if you do.

HOW TO SHARE THE SURVEY WITH SOMEONE ELSE: If you need to share this survey with someone else so that they may also help provide information, you may do so by utilizing the save and return later function. Scroll down to the bottom of the page and clicking "Save & Return Later." On the following page, enter the email of the person that needs to access the survey and click "Send Survey Link." Redcap will send an email to that person containing a link that will allow them to access and finish the survey.

Once we receive the completed survey, you will receive an email notifying you of the negotiator assigned to processing is agreement. If you have any questions you may reach out to us at ResearchContracts@email.wustl.edu

Name of WU Principal Investigator (PI):

* must provide value

Email of WashU PI:

* must provide value

Department of WU Principal Investigator (PI):

* must provide value

Is WU Principal Investigator filling out this form?

Yes

reset

Name of person filling out this form:

* must provide value

Email of person filling out this form:

* must provide value

(optional) Name of additional WU Contact:

(optional) Email of additional WU Contact:

Name of Other Party:

* must provide value

Name of PI at ______:

* must provide value

Name of contact for contracts/legal issues at ______:

* must provide value

Email of contact for contracts/legal issues at ______:

* must provide value

If the proposed agreement is a mulit-party agreement, please list those other
parties here:

Expand

If ______ provided a template, then attach here:

Upload file

Name of the Project:

* must provide value

Expand

Is WashU sending or receiving individual level human data?

* must provide value

WashU is sending

WashU is receiving

WashU is sending and receiving

reset

Is ______'s PI, a former WashU employee who has left in the last 2 years?

* must provide value

Yes

reset

Provide documentation that this transfer has been approved by department leadership (E.g. this could be the PI's departure plan, an email from the former PI's department chair).

* must provide value

Upload file

Description of the project/permitted use of data. This section should provide sufficient information such that each party understands the project that the Recipient will perform using the Data. Content of this section will be very similar to the Statement of Work used in other types of Agreements.

* must provide value

Expand

Are there any other agreements (ex. funding agreements, MTAs, subawards) related to this exchange of data:

* must provide value

Yes

reset

Describe the other agreement(s):

* must provide value

Expand

If available, attach a copy of the other agreement(s):
*if more than one additional agreement, then use attachment fields at the end of the survey.

Upload file

Are you aware of any other obligations or restrictions associated with this project or data that JROC should be aware of? If so, then describe:

Expand

Please answer the following questions regarding the data that WashU is sending.

Describe the data that WashU is sending to ______:

* must provide value

Expand

If you have a list of data points to be transferred to the ______, then attach it here.

Upload file

Please select ALL data elements that Washu will be sending to ______.

Names

Any geocodes that identify an individual household such as a street address or Post Office Box Number

Telephone numbers

Fax numbers

Electronic mail (email) addresses

Social Security numbers

Health plan beneficiary identifiers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers, including license plate numbers

Medical device identifiers and serial numbers

Web universal resource locators (URL)

Internet Protocol (IP) address numbers

Biometric identifiers, including finger and voice prints

Full face photographic images

Geographic subdivision smaller than a state

5 or 9 digit ZIP codes

Any elements of dates (except year), including the date of service, date of birth, date of death, etc.

Specific age over 90 years

Any other unique identifying number, characteristic, or code that could be used by the researcher to identify the individual

Was any part of the data collected under NIH funding after November 2016 or is there a certificate of confidentiality applicable?

Yes

reset

Data from how many individuals will be transferred by WashU to the ______?

* must provide value

Do you have (or are you seeking) IRB approval associated with the original collection of the data?

* must provide value

Yes. from the WashU IRB

Yes, from an outside IRB

No.

What is the IRB number?

* must provide value

What is the source of the data? Check all that apply.

* must provide value

WashU Patient Medical Records (clinical care)

WashU Research Data (including clinical trials)

Third Party Data

Please describe source of and if there was an agreement for the transfer and use of the Third Party Data:

* must provide value

Expand

If Third Party Data was obtained under an agreement, if able, please attached said agreement here:

Upload file

Was the data collected or will it be collected under an informed consent or a waiver of consent?

IRB waiver of consent

Patient was consented

Other

Do you have any other requirements for ______'s use of the data that WashU is sending? If so, please explain:

For example: security standards, authorship expectations, publication embargo periods, ______ must acknowledge source of the data in any publications, ______ must share the results back with you?

Expand

Will ______'s use of the data include the training of an algorithm, machine learning or any other AI development?

Yes

reset

Describe the AI tool and any anticipated end product:

Expand

Is the AI tool already established or is it currently being developed? Please describe the status of the AI tool.

Expand

How will WashU's data contribute to the development or validation of the tool, if at all?

Expand

Please answer the following questions regarding the data that WashU is receiving.

Describe the data that the WashU is receiving from the ______:

* must provide value

Expand

Describe the data that the WashU is receiving from the ______:

*if the data we are receiving is the same as the what we are sending, then please put same.

* must provide value

Expand

Please select ALL data elements that Washu will be receiving from ______.

*if the data we are receiving is the same as the what we are sending, then please select the first option.

The data we are receiving is the same as the data we are sending

Names

Any geocodes that identify an individual household such as a street address or Post Office Box Number

Telephone numbers

Fax numbers

Electronic mail (email) addresses

Social Security numbers

Health plan beneficiary identifiers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers, including license plate numbers

Medical device identifiers and serial numbers

Web universal resource locators (URL)

Internet Protocol (IP) address numbers

Biometric identifiers, including finger and voice prints

Full face photographic images

Geographic subdivision smaller than a state

5 or 9 digit ZIP codes

Any elements of dates (except year), including the date of service, date of birth, date of death, etc.

Specific age over 90 years

Any other unique identifying number, characteristic, or code that could be used by the researcher to identify the individual

Please select ALL data elements that Washu will be receiving from ______.

Names

Any geocodes that identify an individual household such as a street address or Post Office Box Number

Telephone numbers

Fax numbers

Electronic mail (email) addresses

Social Security numbers

Health plan beneficiary identifiers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers, including license plate numbers

Medical device identifiers and serial numbers

Web universal resource locators (URL)

Internet Protocol (IP) address numbers

Biometric identifiers, including finger and voice prints

Full face photographic images

Geographic subdivision smaller than a state

5 or 9 digit ZIP codes

Any elements of dates (except year), including the date of service, date of birth, date of death, etc.

Specific age over 90 years

Any other unique identifying number, characteristic, or code that could be used by the researcher to identify the individual

Do you have (or are you seeking) IRB approval associated with WashU's use of the data that you are receiving from ______?

* must provide value

Yes. from the WashU IRB

Yes, from an outside IRB

No.

What is the IRB number? If the same as an IRB number that was previously provided, then you can put same.

* must provide value

How long, in years, do you need to retain the data that you have received? (project period + any retention period)

* must provide value

Will WashU be sharing the data with any other third party entities collaborating on the project? (i.e. anyone who is not a WashU employee). If so, please list out who.

Expand

Other than the PI, will any other WashU personnel (employees, students, research assistants, etc.) need to access the data that WashU will receive?

* must provide value

Yes

reset

Will the data be housed in a registry that makes the data available to third parties for secondary independent research purposes?

* must provide value

Yes

reset

Who is hosting that registry?

* must provide value

What funding source is supporting your efforts on this project, including your cost to collect, share, and analyze the data?

* must provide value

Department/internal funds

Third-party funding

Who is the third party that is funding this work?

* must provide value

Is either WashU or ______ providing funding to the other for work associated with this project?

* must provide value

Yes and funding is covered in a separate agreement

Yes and funding should be address in this agreement

reset

Please provide budget and payment details, if not already included in the template provided by ______, if any:

Upload file

Please attach the email chain with ______ regarding the sharing of the data, if any.

Upload file

Is there any other information you think would be helpful for us to know?

Expand

Extra attachment:

Extra attachment:

Extra attachment:

Intake form.

Please sign this form by typing your name here. If you are not the PI, then by typing your name here you certify that the PI has reviewed and approved the contents of this form:

* must provide value

Please enter today's date:

* must provide value

M-D-Y

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.