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
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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
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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
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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
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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