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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Co-Investigators, Collaborators, Project Champions, etc. (If Applicable)
Proposed Data Recipient Organization
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Funding Sources (e.g. Funded, Unfunded, Private, Internal, etc.)
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Describe the purpose of the project and data receipient's proposed use of the data. (e.g. Research, Quality Improvement, Operational/Clinical Support, Commercial/Product Development or Other)
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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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Will the data be used for any purposes outside the scope of this proposed or stated use (e.g. algorithm training, market analysis, app development, etc.)?
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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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What type of UCSDH data are you requesting: (e.g. EHR Data, Imaging Data, Biospecimens/Materials, Patient Reported outcomes, Survey or Registry Data, Others?)
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What is the approximate number of patient records requested?
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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? Describe the data de-identification or pseudonymization measures (if applicable). What measures will be in place to prevent re-identification or unauthorized access?
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Will the data be used for a research study by the licensee?
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Yes
No
Will data include the following identifiers? Check all that apply.
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If other, list any additional data elements.
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How long will the data be retained, and what is the plan for secure disposal?
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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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Have you received, or do you expect to receive, any payments or in-kind support from any third parties (such as: vendors, pharmaceutical companies, device manufacturers, insurers, etc.) related to the data requested?
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Yes
No
If yes, please specify the payments or in-kind support received.
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Do you have any agreements for future financial gain (such as: licensing deals, product development, or commercialization agreements) based on access to this data?
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Yes
No
If yes, please explain the nature of the relationship.
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Do you or your collaborators intend to receive funds in exchange of any data from this study to third parties (including commercial entities)?
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Yes
No
If yes, please specify the funds received.
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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
Is a Data Use Agreement (DUA) or Business Associate Agreement (BAA) being contemplated?
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Is this project IRB approved or determined to be not human subjects research?
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Yes
No
Not Applicable (Not a Research Study)
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.