NNDC Mood Outcomes Program Data Request & Data Use Agreement Form

NNDC Mood Outcomes Program Data Request & Data Use Agreement Form
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
NNDC Member Site
Role/Position
Description of Information Requested
Reason/Purpose
List who will have access to the data (name, position/role, organization and email)
Summary of how data will be used (high level description of the planned use of the data, including background, hypothesis, and specific aims)
Data Access and Usage is governed by the NNDC Data Use Policy and NNDC Publications Policy - all requestors must agree to the following:

Data Use Pledge:
- I will not attempt to link individual data records to individual patients or patient identifiers
- I will only use data for the uses authorized by the IRB Letter and Research Protocol submitted with this request
- I will submit a new data request for any new analyses I wish to pursue
- I will not share the data requested outside of the team designated in this request
- I will contact the NNDC for prior approval if I wish to present or publish the data requested
  - For publications, I will follow the guidelines found in the NNDC Publications Policy
- I will destroy the requested data after publication according to FDA rules
- I will store requested data in a HIPAA compliant secure location and indemnify the NNDC and Johns Hopkins University in the case of a security breach
I agree to the Data Use Pledge
If approved, you will receive follow up communications regarding any additional information that is required prior to receiving the data.
Should be Empty: