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.
Please indicate if this is your initial or revised submission.
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

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Is the dataset publicly available?
Will any identifiable private information be recorded in the research database?
Is the data being reviewed / collected for either of the following purposes?
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.)
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)?
If yes, has the PHI been de-identified?
If the PHI has not been de-identified, has a data use agreement with the HIPAA covered entity providing the data been obtained?
Upload agreement here.

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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?
Will informed consent / authorization be sought?
Will / has broad consent be / been utilized?
Does the investigator / study purpose meet any of the following conditions for waiver of consent? (select all that apply)
Please upload the consent document(s) here.

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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
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
Upload letter of authorization to access records here.

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Name of individual submitting request:

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PI /Faculty Advisor Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Revised Documents

This page is for uploading revised documents ONLY. Please use the following fields to upload your revised documents.
Use this space to upload your revised materials in response to conditional approval.

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Use this space to upload additionally revised documents as needed.

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FOR REC USE ONLY DO NOT FILL BELOW THIS LINE
Type of review conducted
Approval Recommended
Conditions to be met prior to approval
Reviewer signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application to Conduct Records-Based Research

Revised Documents

FOR REC USE ONLY DO NOT FILL BELOW THIS LINE