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Radiology Research Data Services Request Form (Honest Broker - Imaging, De-Identification, Data Retrieval)

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The purpose of this form is to request Radiology research data services including Honest Broker services for projects involving medical imaging, Image Retrieval and/or De-Identification Requests.

All Honest Broker requests not including images must be submitted through ServiceNow: https://medschool.duke.edu/pace.

**IMPORTANT--PLEASE READ--This form is for requests pertaining to any or all of the following activities in research:

1) Image data retrieval from the Duke Image Archive. Data may be retrieved within PACE or external to PACE based on the approved data management plan associated with the governing IRB protocol.

2) Data de-identification for images in DICOM format. If the image data are located in PACE with a plan to remove them from PACE after de-identification, the imaging Honest Broker section must be completed.

3) Honest Broker requests related to imaging.

Please note that these requests can only apply to data used for research. Data transfers outside Duke University and Duke University Health System (DUHS) will be referred to the Honest Broker system and must be performed in compliance with Data Transfer Agreements and other agreements through the Office of Research Contracts.

Any requests involving imaging data either obtained or being investigated under a Duke University or DUHS IRB protocol must be in compliance with that study's individual RDSP, approved IRB protocol, and all other applicable data use agreements, institutional policies, and federal regulations. Requests that are found not to be compliant will not be fulfilled.

Submission of this form constitutes an electronic signature acknowledging the above and commitment to adhere to those requirements in relation to potentially sensitive data.

Which of the following categories best describe your request? (check all that apply)

* must provide value

Image Data Retrieval

De-identification

Do you want Image Data Retrieval?

* must provide value

Yes

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Do you want De-identification?

* must provide value

Yes

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Do you want Honest Broker services?

* must provide value

Yes

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Requester's Name

* must provide value

Requester's NetID

* must provide value

Requester's Email Address

* must provide value

CRU/OO Name

* must provide value

Principal Investigator's Name

* must provide value

Principal Investigator's NetID

* must provide value

Principal Investigator's Email Address

* must provide value

IRB Protocol Number

* must provide value

IRB status

* must provide value

Draft

Submitted/Pending Approval

Approved

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Please upload a copy of the approved study protocol

* must provide value

Upload file

Please check which imaging modalities you are requesting to be de-identified

Ultrasound

MRI

X-Ray

PET Scan

Mammography

Nuclear Medicine

Fluoroscopy

Angiography

Other

Please specify "Other" imaging modality you are requesting to be de-identified

* must provide value

Please estimate the number of patient examinations that will be handled in this request.

* must provide value

Please estimate the number of individual images that will be handled in this request.

* must provide value

Please describe your data retrieval needs. Include any special needs for your data set.

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Does your de-identification project require reassignment of file names or meta-data field values to study ID values?

* must provide value

Yes, re-assign meta-data field values (please describe in "details" section)

Yes, re-assign file names (please describe in "details" section)

Yes, re-assign meta-data field values AND file names (please describe in "details" section)

Yes, reassignment with randomized values (please describe in "details" section)

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Do you have any specific metadata fields you would like preserved during de-id?

* must provide value

Yes

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Please list metadata fields to be preserved:

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Please describe any other needs for your data set.

* must provide value

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Please describe the file and folder structure of the data.

Note that our process outputs data as: patient/exam/series/image

* must provide value

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Do you need your data transferred outside of PACE?

* must provide value

Yes

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Please note: Your study requires data delivery outside of PACE, please change your answer to "Yes" for the Honest Broker question above.

Per Duke policy, an Honest Broker review must be completed for data to be transferred outside of PACE.
By submitting this form, you are accepting Honest Broker services for your imaging project.

All non-imaging Honest Broker requests should be placed here: Honest Broker Request .

Please describe the desired location for your data to be transferred, including shared drive path if applicable.

* must provide value

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Do you need the data by a certain date?

* must provide value

Yes

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Enter the date you need the data by:

* must provide value

M-D-Y

Do you want the file name and/or a component of the metadata replaced with an alternate identifier (e.g. study subject number)?

* must provide value

Yes

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This system's primary search method uses accession number, medical record number, date of exam, and modality. Including all of these allows the system to perform error checking and identify discrepancies. Searches can be performed only with accession number, or medical record number + date of exam, but typically more errors are encountered when less information is provided.

Please download and complete the below form by inputting as many of these data types as possible, then upload to the field below. We will perform an initial query based on these data and return results indicating which rows successfully found image data and the exam types, and which rows failed. The requestor will then be asked to review the results, update rows that provided failed queries or unexpected results, or accept that some of the queries have failed, then return the updated spreadsheet for repeat query.

Attachment:HDE-IntakeFormRev1_2_.xlsx

Please attach and upload the completed data template from above containing all of the details for the imaging data requested.

* must provide value

Upload file

Please provide any other details you would like our team to be aware of.

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Please enter the fund code for this request:

By checking this box and submitting this request, you agree to abide by the Terms of Use stated above and attest that, to the best of your knowledge, your request is in compliance with the associated study's RDSP or DRDL, approved IRB protocol, and all other applicable data use agreements, institutional policies, and federal regulations.

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.