Title of Project/Initiative
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Contact Name
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Contact Email
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Requester/PI Name
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Requester/PI Email
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Requester/PI Department
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Proposed Data Recipient Organization
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Describe the purpose of the project and data receipient's proposed use of the data.
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Describe the potential benefits of the project to UC, public health, or healthcare.
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Description of Data to be Released
[Provide a narrative description of the data being shared. This includes amount of data (number of unique individuals), types of data, and the sources of data, including whether the data is derived from the treatment or care of patients at UCSD Health.]
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Does the data contain high-risk health data?
[High-risk heath data includes including HIV, hepatitis, psychiatric illness, substance abuse treatment, laboratory testing for drugs or abuse, sexual orientation and gender identity, and genetic tests.]
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Yes
No
Will data include data from other UC campuses?
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Yes
No
If yes, please list names of the other UC campuses.
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Source(s) of Data
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Explain how the project ensures compliance with relevant regulations and ethical guidelines, such as HIPAA.
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Detail the process for obtaining informed consent from patients, if applicable.
For data generated during a sponsored research trial that appears in the subjects' medical record (i.e. health data), did subjects sign a consent that allows this data to be shared outside the study team?
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Yes
No
Not Applicable
If yes, please attach a copy of the approved consent form
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If no, please explain how subject consent will be obtained or why it is not required.
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In terms of personal identifiers, what is the nature of the proposed data set?
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Identified data
Limited data (HIPAA LDS)
Fully de-identified data
Aggregate data only (counts or other population level statistic)
Is UCSDH responsible for de-identifying the data before sending to third party?
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Yes
No
Indicate whether all 18 HIPAA identifiers will be removed (HIPAA Safe Harbor) or whether a statistical certification (Certification) of de-identification will be obtained. If any dates will be included, indicate how they will be handled (e.g. date-shifting):
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Who is de-identifying the data? How is the data being de-identified?
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Will the data be used for a research study by the licensee?
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Yes
No
Do you hold a management position such as a board member, director, officer, partner, trustee in the entity?
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Yes
No
If yes, please describe the position that you hold and/or the nature of the relationship.
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Do you have an investment or ownership interest in the entity?
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Yes
No
If yes, please explain the nature of the relationship.
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Did you receive income from the entity within the last 12 months?
Income includes any payment, such as salary or consulting fees, royalty payments (paid directly by the entity), reimbursement of expenses (including travel).
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Yes
No
If yes, please specify any financial arrangements or compensation involved in the partnership.
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Are you the inventor or co-inventor of intellectual property (e.g. technology, tangible research materials, copyrighted software, etc.) related to the data that you wish to share/release?
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Yes
No
If yes, please provide the UCSD case number
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Describe any potential conflicts of interest and how they will be managed.
Have you received Department Chair or Division Chief approval?
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Yes
No
If applicable, please provide the IRB number, approval status, and/or attach the IRB protocol.
If applicable, please provide the KR PD number, indicate which office is handling the agreement (OCGA, OCTA, Procurement, HS BC, etc.), and/or attach the DUA.
Please provide any additional information or attach any supporting documents such as protocols, consent forms, grants, contracts, or other information related to this data release request.