数据使用协议（DUA）表格|澳门威尼斯人注册网站研究办公室

1. BU Contact Information:

BU Principal Investigator (PI) Name:*

BU PI Department:*

BU PI Phone*

BU PI Fax

BU PI Email*

BU PI Lab Location*

(Include room, street, and ZIP code.)

(optional) Check here if to specify an alternate BU contact besides the PI.

Alternate BU Contact Name and Email:

2. External Party who will be participating in exchange of Data:

External Party Institution Name:*

External Party PI:*

External Party PI Phone*

External Party PI Email*

External Party Administrative Contact (if known):

External Party Administrative Contact Phone

External Party Administrative Contact Email

3. Who will be sharing Data?*

Inbound - External party will share Data with BU
Outbound - BU will share Data with External party
Mutual - Both parties will share Data

Please describe the nature of the Data you are going to RECEIVE.*

Please describe the nature of the Data you are going to PROVIDE.*

Please describe the nature of the Data that the parties are going to EXCHANGE.*

4. If BU is the RECIPIENT, provide the BU location of where research using the data will be conducted. (***If you know, please reference the BU computing environment, e.g., BU network drive, BU Shared Computing Cluster, BU Microsoft SharePoint/Teams for collaboration, and list any devices that will be used to store or access the data, including any devices that are not owned or managed BU.***) If BU is the PROVIDER, provide the BU location of the research that generated the data.*

(Include room, street, and ZIP code.)

5. If BU is the RECIPIENT, provide a description of the research to be conducted with Data. If BU is the PROVIDER, provide a description of the research that generated the Data (please provide project title(s), grant/award number(s), sponsor(s) name(s)).*

6. Are you accessing Framingham Heart Study (FHS) data?*

Yes
No

7. a. Does the data contain information collected from human research subjects?*

Yes
No

7. b. Does the data contain any identifiers, individually identifiable health information or protected health information (PHI)?*

Yes
No

Please provide your IRB protocol number.*

IRB Documentation*

Please upload applicable IRB documents (e.g., BU IRB approval letter)

Drop files here or

Max. file size: 100 MB.

8. Is this DUA being requested for a Subaward or Subcontract?*

Yes
No

Please provide your Subaward/Subcontract number.*

9. If BU is the RECIPIENT, how will you fund the research to be conducted with the Data? If BU is the PROVIDER, how did you fund the research that generated the Data?*

Please provide grant/award number, if applicable.

10. Do you anticipate that any inventions will be developed by you from the use of the Data?*

Yes
No

Please discuss in as much detail as possible.*

11. Will the Data be used in conjunction with other research?*

Yes
No

Please provide the sponsor(s) name(s), project title(s) and sponsored project number(s).*

12. Other than PHI, do you anticipate sending any Confidential Information as a part of this transfer?*

Yes
No

13. Do you plan to publish the results of the research using these Data?*

Yes
No

Please provide a brief description of your plan.*

14. Does the sponsor indicate that any of the following restrictions or limitations will be applied to your activities under this agreement? Please check all that apply.*

Not Applicable
Prior approval for dissemination/publications
Restrictions on access or participation by foreign nationals
Export control restrictions [International Traffic Arms Regulations (ITAR), Export Administration Regulations (EAR), Nuclear Regulations]

Principal Investigator Certification: I certify that the information I have provided about this project is accurate. Furthermore I certify that I will direct this project in compliance with Boston University policies, and with all applicable laws and regulations.

Signature*

Date*

Upload any relevant documentation (e.g., Word version of draft agreement from external party, IRB approval letter, etc.) here:

Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, Max. file size: 100 MB.

Email

This field is for validation purposes and should be left unchanged.

Data Use Agreement (DUA) Form

Complete Form

Principal Investigator Certification: I certify that the information I have provided about this project is accurate. Furthermore I certify that I will direct this project in compliance with Boston University policies, and with all applicable laws and regulations.

Information For...

Information For...