UNI VE RS I T Y O F P IT T SB UR GH O FFI C E O F RE SE AR C H EXAMPLE OF M Y RA SUBMISSION QUESTIONS****SUBMISSION MUST BE MADE IN M Y RA SYSTEM**** To Log in to MyRA: http://myra.pitt.edu/MyRA/ D A TA U S E A GR E EM E N T (DUA) Basic Information 1. 2. 3. 4. 5. Principal Investigator: Department/Institute/Center that will be administratively responsible for this Agreement: Is the draft of the agreement attached? Title of Submission: Department Administrative Contact: Department/Institute/Center Name: Department/Institute/Center ID: Yes, Draft agreement attached No, Pitt to Generate First Draft No, this is an Addgene Order No, this is an NCI dbGaP Study No this is an NCI Development Therapeutics Study Other, please explain: Name: E-Mail: Contracting Party Information 1 2. 3. 4. 5. 6. 7. Contracting Party Name: Legal Contact Name: Legal Contact E-Mail Address: Legal Contact Phone Number: Scientific Contact Name: Scientific Contact E-mail: Does the Principal Investigator have a financial relationship with any of the Contracting Parties listed above that is or should be disclosed on your University of Pittsburgh Conflict of Interest disclosure form? Yes No If Yes, please explain: Pitt Principal Investigator will be SENDING data (complete sections labeled “Sending” below) Pitt Principal Investigator will be RECEIVING data (complete sections labeled “Receiving” below): If Pitt Principal Investigator will be both SENDING and RECEIVING data please complete both sections. Form Revision Date: 3/15/15 Page 1 INTERNAL SUBMISSION FORM F O R TH E R E V I E W O F D A T A U S E A G R E E M E N TS ( D U A ) Data Information (Sending) 1. 2. Description of data: Purpose of sending the data: Compliance Information (Sending) 1. What is the origin of this data? Animal Student (or Educational) Human Subject Research, attach IRB approval letter Other. If other, explain: Human Subject Research Information (Sending) 1. 2. 3. 4. Attach IRB Approval Letter Was the data collected under Informed Consent? Is the data identifiable? Is the data a Limited Data Set (LDS)? Yes No Yes, if yes, please explain: No Yes No If yes, check the applicable fields that will be provided: Dates Zip Codes Other, please explain: Funding Information (Sending) 1. Is the source of funding: 2. Indicate the funding source used to collect the data: 3. Are there any other agreements/funding/materials applicable to your research (consider all that apply, i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License, MTA, Subcontract, Other Agreement)? Internal (e.g. departmental or start-up funding) External (e.g. sponsored research) Funding Source: Grant Identifier/Award #: PI of Grant Funds: Are Funds Housed a Pitt? Yes No If no, where are funds housed? Yes No If yes Please list the agreements: Institution Number: Project Details: Does this agreement address data sharing with this recipient? Yes. If yes, please explain: No Recipient Information (Sending) 1. Do you require reimbursement for the cost to provide the data? Yes. If yes, please explain: No Form Revision Date: 3/15/15 Page 2 INTERNAL SUBMISSION FORM F O R TH E R E V I E W O F D A T A U S E A G R E E M E N TS ( D U A ) 2. Do you require the recipient to collaborate, share results or anticipate that they will jointly publish with you? Yes. If yes, please explain: No Restrictions Information (Sending) 1. 2. Are you aware of any restrictions or confidentiality obligations that would impact sharing of this data? Is the data under disclosure to or patented by Pitt Office of Technology Management (OTM)? Yes. If yes, please explain: No Yes No If yes: OTM Staff: OTM Case Number: Form Revision Date: 3/15/15 Page 3 INTERNAL SUBMISSION FORM F O R TH E R E V I E W O F D A T A U S E A G R E E M E N TS ( D U A ) Data Information (Receiving) 1. 2. Description of data: Purpose of sending the data: Compliance Information (Receiving) 1. What is the origin of this data? Animal Student (or Educational) Human Subject Research Other. If other, explain: Human Origin Information (Receiving) 1. 2. 3. 4. Attach IRB Approval Letter Was the data collected under Informed Consent? Is the data identifiable? Is the data a Limited Data Set (LDS)? Yes No Yes, if yes, please explain: No Yes No If yes, check the applicable fields that will be provided: Dates Zip Codes Other, please explain: Funding Information (Receiving) 1. Is the source of funding: 2. Indicate the funding source used to collect the data: 3. Are there any other agreements/funding/materials applicable to your research (consider all that apply, i.e., Sponsored Research Agreement, Government or Other Grant, CDA, License, MTA, Subcontract, Other Agreement)? Internal (e.g. departmental or start-up funding) External (e.g. sponsored research) Funding Source: Grant Identifier/Award #: PI of Grant Funds: Are Funds Housed a Pitt? Yes No If no, where are funds housed? Yes No If yes Please list the agreements: Institution Number: Project Details: Does this agreement address data sharing with this recipient? Yes. If yes, please explain: No Data Use Information (Receiving) 1. Will you make a derivative or modification of the received data? Yes. If yes, please explain: No 2. Do you intend to collaborate, share results or anticipate that you will jointly publish with the sender? Yes. If yes, please explain: No Form Revision Date: 3/15/15 Page 4 INTERNAL SUBMISSION FORM F O R TH E R E V I E W O F D A T A U S E A G R E E M E N TS ( D U A ) 3. Do you intend to share this data with non-Pitt persons? Yes. If yes, please explain: No If yes, What data will you share? Received Data Modified Data Restrictions Information (Receiving) 1. Are you aware of any restrictions or confidentiality obligations that relate to hardware, software or office security? Yes. If yes, please explain: No 2. Does the data need to be stored and managed per any cited electronic security standards? Yes No If yes, provide Department IT staff name: Department IT staff e-mail: Additional Information 1. Additional information relevant to the review of this request, including any time constraints: DO NOT EMAIL THIS FORM. IT IS AN EXAMPLE OF M Y RA SUBMISSION QUEST IONS - ALL SUBMISSIONS MUST BE MADE IN M Y RA SYSTEM To Log in to MyRA: http://myra.pitt.edu/MyRA/ Form Revision Date: 3/15/15 Page 5