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Meta-Data De-Identification Request for DICOM Image Data

Please fill in the below request form. Note that if this request is for data in PACE, both this request and a Federated Honest Broker request will need to be submitted. Please email Bashir.Lab-deid@dm.duke.edu with any questions.
Thank you!

**IMPORTANT--PLEASE READ--This form is for requests for one or both 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, a separate imaging Honest Broker request must be completed.

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)

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Image Data Retrieval

De-identification

Do you want Image Data Retrieval?

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Yes

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Do you want De-identification?

* must provide value

Yes

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Requester's Name

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Requester's NetID

* must provide value

Requester's Email Address

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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

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Draft

Submitted/Pending Approval

Approved

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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.

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

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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?

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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.

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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

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Do you need your data transferred outside of PACE?

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Yes

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Have you completed a Radiology Honest Broker request?

* must provide value

Yes

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Please provide Radiology Honest Broker request ID

* must provide value

Per Duke policy, an Honest Broker request must be completed for data to be transferred outside of PACE.
Honest Broker requests related to medical imaging should be placed Honest Broker Service Request - Imaging:
All other 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.

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Do you need the data by a certain date?

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Yes

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Enter the date you need the data by:

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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)?

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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 job:

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, approved IRB protocol, and all other applicable data use agreements, institutional policies, and federal regulations.

* must provide value

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