Project Feasibility and Data Access Quote Form
For assistance in completing this form, please contact our Project Coordinator at (506) 447-3320. Allow a
minimum of 10 working day for processing of form.
APPLICANT INFORMATION:
Full name:
Email address:
Telephone:
(xxx) xxx-xxxx
Mailing address:
Affiliation:
Choose one
If other, describe:
Name of affiliation:
Is this a thesis?
Position:
☐Yes ☐No
NB-IRDT Researcher:
Academic unit:
Supervisor:
RESEARCH TEAM:
Provide the following details for those who will be doing data analysis in the NB-IRDT lab.
Name
Position
Organization
FUNDING:
Source of funding:
Name of PI on funding submission:
Affiliation:
Have you applied for funding?
☐Yes ☐No
Project term:
Start date: (yyyy-mm-dd)
Effective date: Month xxxx
Review date: Month xxxx
Amount expected:
End date: (yyyy-mm-dd)
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Project Feasibility and Data Access Quote Form
PROJECT DETAILS:
Full project title:
Briefly explain the purpose of this project. What are the overall objectives?
Type of submission:
Choose one
Is this project associated with another NB-IRDT project?
☐Yes ☐No
If yes: title and reference number:
Is this an MSSU project? ☐Yes ☐No
Type of analysis:
Choose one
Type of study:
Choose one
Provide a brief description of the methodology planned for this project:
Estimated number of days to complete research:
(if more than one person is involved, include every researcher’s day as 1 day)
List any analytical support you wish NB-IRDT to provide (e.g. data setup, analysis, etc):
RESEARCH REQUIREMENTS:
All data sources being used for the study and requiring approvals - both NB-IRDT and non-NB-IRDT data must be identified. Descriptions of the following data sets can be found at go.unb.ca/fr-nbirdt.
Indicate which of the following NB-IRDT data sets will be required and identify the time span of
interest:
NB-IRDT Data Set
Start (yyyy-mm-dd)
End (yyyy-mm-dd)
☐Citizen Database
(yyyy-mm-dd)
(yyyy-mm-dd)
☐ Hospital Discharge Abstract Data
(yyyy-mm-dd)
(yyyy-mm-dd)
☐Provider Registry
(yyyy-mm-dd)
(yyyy-mm-dd)
Effective date: Month xxxx
Review date: Month xxxx
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Project Feasibility and Data Access Quote Form
☐Vital Stats
(yyyy-mm-dd)
(yyyy-mm-dd)
☐Physician Billing (coming soon)
(yyyy-mm-dd)
(yyyy-mm-dd)
☐BizNet (coming soon)
(yyyy-mm-dd)
(yyyy-mm-dd)
☐ Long Term Care (coming soon)
(yyyy-mm-dd)
(yyyy-mm-dd)
Will this project involve linking NB-IRDT data with external data?
(If yes, please complete Appendix 1)
☐Yes ☐No
Are there any other issues that NB-IRDT staff should be aware of pertaining to this project?
Effective date: Month xxxx
Review date: Month xxxx
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Project Feasibility and Data Access Quote Form
Appendix 1. Database Not Available in the NB-IRDT Repository
Completion of this appendix is required only if your project is proposing to use a data source not
currently held as an ongoing database in the NB-IRDT data repository. The principal investigator must
arrange for any individual identifiers or fields that could directly identify an individual to be removed
from the data and replaced with the appropriate encrypted identifiers prior to the data being sent to NBIRDT.
DATABASE INFORMATION:
Full title of project:
Principal Investigator:
Database name:
Database source:
Contact person at source:
Organization approving use of data:
DATABASE SCOPE:
For example, this includes personal information or personal health information contained in the data,
start/end dates, general content (e.g., injury occurrence reports), whether the data is individual or
aggregate level.
DATA SHARING:
☐ A Data Sharing Agreement is in place for the ongoing transfer of data to NB-IRDT.
NOTE: Use of the data will require separate approvals for each project from the identified
organization(s).
☐ Data will only be used for this specific project.
NOTE: Copies of all supporting documentation must be provided to NB-IRDT for using and transferring
the data to NB-IRDT.
Effective date: Month xxxx
Review date: Month xxxx
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Project Feasibility and Data Access Quote Form
REQUIREMENTS FOR THE TRANSFER AND USE OF PROJECT-SPECIFIC DATA:
I understand that project-specific data will only be used as part of the identified project and that the
principal investigator is responsible for arranging the collection and disclosure of project specific data to
NB-IRDT with all of the necessary additional approvals, which may include:


Primary data (e.g. survey or chart review) - must include a copy of the appropriate REB approvals for
collection and use, including a blank copy of the original informed consent form.
Secondary data (e.g. administrative data) - must have a specific data sharing agreement from the
original data provider indicating that the data will be housed at NB-IRDT for the identified project.
I also understand that project-specific data will be destroyed or archived and removed from the NB-IRDT
analysis system at the completion of the project, or earlier if there is a specific termination date for use
or access of the data.
Signature of Applicant:
Name:
Click here to enter name.
Date:
Click here to enter a date.
Effective date: Month xxxx
Review date: Month xxxx
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