COMIRB Protocol #
* must provide value
If you do not have a COMIRB Protocol #, please provide a brief explanation
Primary Contact (Your Name)
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Your Phone Number
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Your Email Address
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Department
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CTR-AdvancingProfessionalExcellence CTR-AlzheimersDisease CTR-AnschutzHealth-Wellness CTR-BarbaraDavis CTR-Bioethics-Humanities CTR-CTRIC CTR-ColoradoHealthOutcomes CTR-Depression CTR-Gait-Movement Analysis CTR-Gene-Environment-Health CTR-Hemophilia-Thrombosis CTR-HumanNutrition CTR-HumanSimulation CTR-InstructionalSupport CTR-Intellectual-Developmental-Disabilities CTR- LindaCrnic-DownSyndrome CTR-MarionDownsHearing CTR-NutritionObesityResearch CTR-PerinatalResearch CTR-RockyMtnTaste-Smell CTR- SickleCellTx-Research CTR-SurgicalInnovation CTR-SurgicalTx LungInfection CTR-TraumaResearch CTR-WebbWaring Cancer Clinical Trial Office College-Nursing DHHA-ADMINISTRATION DHHA-ANESTHESIOLOGY DHHA-BEHAVIORAL HEAL DHHA-ACS/CHS DHHA-BUSINESS DEV DHHA-CORRECTIONS DHHA-EMERGENCY MED DHHA-MANAGED CARE DHHA-MEDICINE DHHA-NURSING DHHA-OB/GYN DHHA-OFFICE OF ED DHHA-OFFICE OF RES DHHA-ORTHOPEDICS DHHA-PATIENT SAFETY DHHA-PHYSICAL THERAPY DHHA-SOCIAL WORK DHHA-PEDIATRICS DHHA-PHARMACY DHHA-PUBLIC HEALTH DHHA-RADIOLOGY DHHA-RMPDC DHHA-SURGERY DHHA-EHEALTH SERVICE SOM-Anesthesiology SOM-Biochemistry-MolecularGenetics SOM-Cell-DevelopmentalBiology SOM-Dermatology SOM-EmergencyMedicine SOM-FamilyMedicine SOM-Immunology SOM-Medicine SOM-Microbiology SOM-Neurology SOM-Neurosurgery SOM-ObstetricsGynecology SOM-Ophthalmology SOM-Orthopedics SOM-Otolaryngology SOM-Pathology SOM-Pediatrics SOM-Pharmacology SOM-PhysMedicine-Rehab SOM-Physiology-Biophysics SOM-Psychiatry SOM-RadiationOnc SOM-Radiology SOM-Surgery School-DentalMedicine School-Pharmacy School-PublicHealth UCH - Northern Colorado - Cardiology UCH - Northern Colorado - Trauma UCH - Northern Colorado - Oncology UCH - Northern Colorado - Orthopaedics UCH - Northern Colorado - Infectious Disease UCH - Northern Colorado - Dermatology UCH - Northern Colorado - Pharmacy UCH - Northern Colorado - Neurosciences UCH - Northern Colorado - External Provider UCH - Colorado Springs Acute Care Rehab UCH - Colorado Springs - Cardiology UCH - Colorado Springs Emergency Department UCH - Colorado Springs Forensic Nursing UCH - Colorado Springs - Trauma UCH - Colorado Springs - Oncology UCH - Colorado Springs - Orthopaedics UCH - Colorado Springs - Infectious Disease UCH - Colorado Springs - Pharmacy UCH - Colorado Springs - Pulmonary UCH - Colorado Springs - Neurosciences UCH - Denver Metro - Nursing UCH - Denver Metro - Pharmacy Other
Name of Collaborating Institution / Other Party
(i.e. name of external collaborating institution)
* must provide value
Include names of ALL parties
Agreement Type
* must provide value
BAA
DUA
DTUA (Deidentified Data)
Non Employee Agreement (DHHA)
dbGap
Other
BAA
DUA
DTUA (Deidentified Data)
Non Employee Agreement (DHHA)
dbGap
Other
COMIRB protocol number
or Contract number
Briefly describe the data
included in the agreement
University contact for this
DUA (from school/unit/department)
Department:
Tel:
e-mail:
PI name:
On which server will this information be stored
Agreement Type 'Other' Name
PI Name
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Have you selected DHHA or dbgap under Agreement type?
No
Yes
PHI Data Elements that will be provided
(Please check ALL that apply)
* must provide value
Name
Location
Dates
Telephone numbers
Fax numbers
Email addresses
Social security numbers
Medical record numbers
Health plan beneficiary numbers
Account numbers
Certificate / license numbers
Vehicle identifiers
Device identifiers
Web Universal Resource Locators (URLs)
Internet Protocol (IP) address numbers
Biometric identifiers
Full face photographic images
Any unique identifying number, character, code
Other - explain below
Name
Location
Dates
Telephone numbers
Fax numbers
Email addresses
Social security numbers
Medical record numbers
Health plan beneficiary numbers
Account numbers
Certificate / license numbers
Vehicle identifiers
Device identifiers
Web Universal Resource Locators (URLs)
Internet Protocol (IP) address numbers
Biometric identifiers
Full face photographic images
Any unique identifying number, character, code
Other - explain below
Reason for Data Use
* must provide value
Data Flow - Is CU providing or receiving the data?
* must provide value
Providing
Receiving
BOTH Providing and Receiving
Providing
Receiving
BOTH Providing and Receiving
Person Managing Data for CU - Name
* must provide value
Person Managing Data for CU - Phone Number
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Person Managing Data for CU - Email
* must provide value
Phone Number
* must provide value
Email
* must provide value
Phone Number
* must provide value
Email
* must provide value
Describe the system/application used for collection, storage and management of data and storage locations
* must provide value
Encrypted Email
Encrypted Laptop
CU Anschutz - Secure Server
REDCap
One Drive
Flash Drive
Hard Copy
Other - explain below
Encrypted Email
Encrypted Laptop
CU Anschutz - Secure Server
REDCap
One Drive
Flash Drive
Hard Copy
Other - explain below
'Other' system/application used for collection, storage and management of data and storage locations - INCLUDE data security plan
* must provide value
Data Transmission Method
* must provide value
Encrypted Email
REDCap
One Drive
Other - explain below
Encrypted Email
REDCap
One Drive
Other - explain below
'Other' Data Transmission Method - INCLUDE data security plan
Data on Mobile Device(s)
* must provide value
Yes
No
Mobile Device(s) Encrypted
* must provide value
Yes
No
Password protection on mobile devices triggers encryption
Data Accessible via Internet
* must provide value
Yes
No
Describe (in detail) Data Plan for End of Study or when you are otherwise finished using the data
* must provide value
How will you ensure ongoing data security? (Ex. destroy, return, retain securely by..., etc.)
Upload BAA/DUA/Other Agreement Template
Please attach/upload any documents you wish to share related to this request
Upload Underlying Agreement (such as, Master Services Agreement, etc.)
Please attach/upload any documents you wish to share related to this request
Please provide any other pertinent information
Upload final, fully-executed document
Upload additional fully executed documents
Today D-M-Y
Other Entity Signature Date
Today D-M-Y
Today D-M-Y
ORC reviewed and approved?
Yes
Submit
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