Application to Conduct Records-Based Research

Application to Conduct Records-Based Research

Research Ethics Committee
This form is for records review research proposals only. Please complete each section as it applies to your research. If additional space is needed to fully explain any of the requested information, please upload appendices in the space provided.
Title of Study:*
Name of principle investigator (PI) / faculty advisor on project*
PI / Faculty Advisor Email*
example@example.com
Name of student/co investigator
Please describe the dataset / records you are requesting access to for this study:*
Please briefly explain the purpose of the research and how you plan to utilize the data. Please use the box below to add attachments as needed for longer descriptions or to include related documents.*
File Upload

Cancelof
Is the dataset publicly available?*

YESNO
Will any identifiable private information be recorded in the research database?*

YESNO
Is the data being reviewed / collected for either of the following purposes?*

Public health activities and purposesHealth care operationsNO
Does the proposed records-based research present any more than minimal risk to human subjects (or could it if the data were disclosed)? (Note: risk is not limited to physical risk and may also include risk to socioeconomic status, employability, emotional well-being, reputation, etc.)*

YESNO
Does this proposed records-based research include data that was collected under any of the categories eligible for expedited review? See the REC website for complete descriptions of each category. *
Does the proposed records-based research involve access to protected health information (PHI)?*

YESNO
If yes, has the PHI been de-identified?*

YESNO
If the PHI has not been de-identified, has a data use agreement with the HIPAA covered entity providing the data been obtained?*

YESNO
Upload agreement here.

Cancelof
Will identifiers be removed / destroyed? Please explain why or why not, and at what point the identifiers will be removed. *
Does the proposed records-based research involve access to personally identifiable educational records?*

YESNO
Will informed consent / authorization be sought?*

YESNO
Will / has broad consent be / been utilized?*

YESNO
Does the investigator / study purpose meet any of the following conditions for waiver of consent? (select all that apply)

investigator is a school official, teacher or other employee within the agency or institution with legitimate educational interests.investigator is a contractor, consultant, volunteer, or other party to designated by the organization to perform functions that would otherwise be performed by employees; is under direct control of the organization with regards to use of the education records; and is subject to 34 CFR 99.33(a)purpose is to develop, validated or administer predictive testspurpose is to administer student aid programspurpose is to improve instruction
Please upload the consent document(s) here.

Cancelof
Please describe the risk associated with this research.*
How will risk be minimized?*
How will the data be stored and confidentiality be maintained?*
Estimated Starting Date*

MonthDayYear
Date
Estimated Duration*
Name of person/s authorizing access to investigator

First NameLast Name
Email of person/s authorizing access to investigator
example@example.com
Phone Number of person/s authorizing access to investigator
Please enter a valid phone number.
Upload letter of authorization to access records here.

Cancelof
Name of individual submitting request:*

First NameLast Name
Role of individual submitting the request:*
Email*
example@example.com
Signature*

Clear
Date

MonthDayYear
Date
PI /Faculty Advisor Signature

Clear
Date

MonthDayYear
Date

Application to Conduct Records-Based Research

FOR REC USE ONLY DO NOT FILL BELOW THIS LINE