Third-Party Access Protocol
Q1 IF THERE ARE PERSONAL IDENTIFIERS IN THE DATA TO BE ACCESSED, (EVEN IF
YOU AREN'T REPORTING THEM) YOU MUST SUBMIT THIS FORM
Q2 Responsible Investigator Name [Faculty research mentor, if student research]
Q3 Responsible Investigator E-mail
Q4 Department Chair/Program Director Name
Q5 Department Chair/Program Director E-mail
Q6 Student Investigator Name [Do not include student research assistants for faculty research]
Q7 Student Investigator E-mail
Q8 Title of Project
Q9 Concisely describe how existing data will be involved in the proposed research
Q10 Professional qualifications [to do the proposed research]
Q11 Funding Source [If the research is grant-supported or contract research]
Q12 Purpose of the proposed research [Provide an explicit statement of what is and is not
known about the topic, indicating what the proposed research is intended to add, stated as
benefits to the discipline and to the subjects. The IRB makes a cost/benefit analysis weighing
the potential benefits of the research against the potential costs and risks to the subjects.]
Q13 For the original data collection, was informed consent obtained for:
Select one for each statement
Yes (1)
No (2)
Data use for program
evaluation (1)


Data use for research
purposes (2)


Q14 If you answered Yes to the above question, please append written evidence
Q15 Provide a specific and meaningul description of the information for which access is
requested. Variable lists are appropriate, if the variables are explained. Directly address
whether personal identifiers will be included.
Q16 Explain why the research could not practicably be conducted without access to the data
Q17 Explain why consent of the subjects could not practicably be obtained
Q18 If you answered above that consent has not been obtained for data use for program
evaluation, please show that the individuals—even if personal identifiers are absent—will not be
placed at greater risk by the research [for example by substantial risk of loss of benefits
depending upon the results obtained].
Q19 If personal identifiers are present in the data to be accessed, show how each of the
following is present:
Q20 An adequate plan to protect identifiers from misuse
Q21 An adequate plan to destroy the identifiers at the earliest opportunity consistent with the
research and law
Q22 Adequate assurances that the data will not be disclosed to any other person or entity
except as required by law
Q23 Adequate oversight of the research project
Q24 Attach an additional document here [for example, authorization from an agency]
The actual form has an attachment button
Q25 Attach an additional document here [for example, authorization from an agency]
The actual form has an attachment button
Q26 Attach an additional document here [for example, authorization from an agency]
The actual form has an attachment button
Q27 When the information in this protocol is complete, checked, approved by the faculty mentor
-- if a student project -- proceed to the submission section.
Q28 Required
 I affirm the accuracy and truth of the information in this document (1)
Q29 Required
 I understand that submission is the first step in the IRB review and authorization process. I
will receive a submission confirmation E-mail after I submit this form. (1)