The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

UiMj5Bw7oNfAD2JnZIFuHhM6Ks

Office of Research Contracts (ORC) Data Transfer Intake Form (DTIF) for IRB Review

Please complete the form below.

This form is for internal use only.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Submitter's Information

First name

* must provide value

Last name

* must provide value

NetID

* must provide value

If data is flowing both ways, list Duke as the Discloser and the other party as Recipient.

Discloser's Information

Discloser (data will be transferred from)

* must provide value

Duke

Other

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Specify other Discloser

* must provide value

What is the source of Duke's initial collection of the data?

Standard of care

Research study

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What is the name of the initial research study?

What is the initial research study IRB number?

If applicable, what is the source of the funding for the initial study?

If applicable, what is the initial SPS#?

The information below is requested in connection with the research to be performed using the data.

Name of PI of Discloser's research study

Discloser's research study name

Discloser's IRB number

Discloser's research study source of funding

Discloser's SPS#

Recipient Information

Recipient (data will be transferred to)

* must provide value

Duke

Other

reset

Specify other Recipient

* must provide value

Recipient PI name

Study name

Recipient's eIRB number

Recipient's research study source of funding

Recipient's SPS#, if any

Recipient will use data for

Registry

Business operations

Research study

reset

Data Information

Specify data flow

*indicate all that apply

* must provide value

data one way

data both ways (i.e., to and from each party)

results either or both ways

Discloser will provide data to the Recipient via

*indicate all that apply

Access credentials to the file server

Duke Box (Duke IRB prefers the use of Duke Box when possible)

REDCAP

Other Internet file transfer system

Physical digital media, such as flash drive or hard drive

Physical printed media, such as paper binder

Please check all HIPAA identifiers that will be disclosed and provide a list of data elements below.

* must provide value

Names

Geographic designation, other than country or state, including street address, city, county, precinct, ZIP Code, and their equivalent geographical codes

ZIP Codes, in whole or in part

All elements of dates (except year alone) directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older

Telephone numbers

Facsimile numbers

Electronic mail addresses

Social security numbers

Medical record numbers

Health plan beneficiary numbers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers, including license plate numbers

Device identifiers and serial numbers

Web universal resource locators (URLs)

Internet protocol (IP) address numbers

Biometric identifiers, including fingerprints and voiceprints (including audio recordings)

Full-face photographic images and any comparable images

Any other unique identifying number, characteristic or code

None of the above

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