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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

Data Sharing Request Portal

Welcome to the University of Colorado Denver | Anschutz Medical Campus online Data Sharing Request Portal for the web-based submission and routing of data sharing agreement (such as Business Associate Agreement, Data Use Agreements, Data Transfer Agreements).

The below online form should be used for submission of data-related requests. At the end of the form, there is a free-text field where you can provide any notes or helpful information. There is also an opportunity to upload documents for our review.

Upon submission of the form, the Office of Regulatory Compliance will automatically be notified of your request and someone will be in touch with you soon. Please direct any separate communications regarding data sharing requests/agreement to reg.compliance@CUAnschutz.edu .

STOP! Do not submit CDAs, Confidentiality Certificates, Non Monetary Research Collaborations, or MTAs through this process. Please use this link instead https://ucdenverdata.formstack.com/forms/rss_ra_ogc_ra

COMIRB Protocol #

* must provide value

Primary Contact (Your Name)

* must provide value

Your Phone Number

* must provide value

Your Email Address

* must provide value

Department

* must provide value

Name of Collaborating Institution / Other Party
(i.e. name of external collaborating institution)

* must provide value

Expand

Agreement Type

* must provide value

BAA

DUA

DTUA (Deidentified Data)

DTUA (Identifiable Data)

Non Employee Agreement (DHHA)

dbGaP/Extramural Institutional Certification

Other

Agreement Type 'Other' Name

Upload BAA/DUA/Other Agreement Template

Upload file

Upload Additional Agreement

Upload file

Upload Additional Agreement

Upload file

Name

IRB Protocol

PI/Responsible Party

Contact #

Responsibilities

Expand

COMIRB protocol number
or Contract number

Study Title

Briefly describe the data
included in the agreement

Expand

University contact for this
DUA (from school/unit/department)

Department:
Tel:
e-mail:
PI name:

Expand

On which server will this information be stored

PI Name

* must provide value

PI Phone Number

PI Email Address

Upload an email confirming that the University of Colorado is able to submit on behalf of other institution(s)

Upload file

If you include other institution on the extramural certificate, upload an email from the outside entity confirming approval to provide data to the NIH.

Upload file

Have you selected dbGaP under Agreement type?
(If you select "Yes" please upload the approved informed consent form (ICF)

Yes

Project/Protocol Title

Description of Data

Expand

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

'Other' Data Description

Expand

Reason for Data Use

* must provide value

Expand

Data Flow - Is CU providing or receiving the data?

* must provide value

Providing

Receiving

BOTH Providing and Receiving

reset

Person Managing Data for CU - Name

* must provide value

Person Managing Data for CU - Phone Number

* must provide value

Person Managing Data for CU - Email

* must provide value

Name

* must provide value

Phone Number

* must provide value

Name

* must provide value

Phone Number

* 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

'Other' system/application used for collection, storage and management of data and storage locations - INCLUDE data security plan

* must provide value

Expand

Data Transmission Method

* must provide value

Encrypted Email

REDCap

One Drive

Other - explain below

'Other' Data Transmission Method - INCLUDE data security plan

Expand

Data on Mobile Device(s)

* must provide value

Yes

reset

Mobile Device(s) Encrypted

* must provide value

Yes

reset

Data Accessible via Internet

* must provide value

Yes

reset

Describe (in detail) Data Plan for End of Study or when you are otherwise finished using the data

* must provide value

Expand

Please provide any other pertinent information

Expand

Upload final, fully-executed document

Upload file

Upload additional fully executed documents

Upload file

CU Signature Date

D-M-Y

Other Entity Signature Date

D-M-Y

Fully-Executed Date

D-M-Y

ORC reviewed and approved?

Yes

Internal Communications

Expand

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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.