ࡱ> bea !"bjbj 4P}c}c4 QQQQQeee8dTe_9U,8888888$;=9Q9QQ9###jQQ8#8##J57Pѯ>58/90_96>t>,7>Q7#994!b_9> : SAINT LOUIS UNIVERSITY INTERNAL DATA USE AGREEMENT (DUA) FOR RESEARCH USES OF A LIMITED DATASET 91Ů (91Ů) researchers requesting to receive a Limited Dataset derived from records in the 91Ů system, including SSM sites, should complete this form to certify research use of a Limited Dataset. To qualify as a Limited Dataset, the dataset can only include the following HIPAA identifiers: city/state/zip codes, subject-specific dates (date of birth, dates of service) and age. If your study requires receiving HIPAA identifiers beyond those (see  HYPERLINK \l "AppendixA" Appendix A), your study is not eligible for an Internal DUA and likely requires IRB approval (contact the IRB Office at 977-7744 or  HYPERLINK "mailto:irb@slu.edu" irb@slu.edu for guidance). This form is appropriate for scenarios in which a third party Honest Broker (e.g., an EHR system administrator), who has access to medical records as part of their institutional role and is not part of the research team, performs the data abstraction and provides only a Limited Dataset to the research team. It should not be used when the research team is accessing identifiable health records and directly abstracting data (which requires an IRB Application). This form should also not be used for research projects being submitted in the eIRB system; the Internal DUA is built into eIRB Applications directly. Please complete the following including Appendix B: Principal Investigator (Data User): Phone/Pager: Department: E-mail: Contact Person: E-mail: Phone: Project Title:  Data to be used in this study will be obtained from the following entitys records:  FORMCHECKBOX  91Ů  FORMCHECKBOX  SSM Heath 91Ů Hospital  FORMCHECKBOX  SSM Health Hospitals (Other) Data to be recorded in the dataset for this study include:  FORMCHECKBOX  City/State/Zip Codes  FORMCHECKBOX  Subject-Specific Dates (date of birth, dates of service, etc.)  FORMCHECKBOX  Age (if subjects are 90 years or older) NOTE: If any other HIPAA identifiers are being recorded per the listing in  HYPERLINK \l "HIPAAidentifiers" Appendix A, you do not qualify for an Internal Data Use Agreement. HIPAA Authorization or a Waiver of Authorization and IRB review will likely be required. Contact  HYPERLINK "mailto:irb@slu.edu" irb@slu.edu or 314-977-7744 with questions. Obligations of Data User: Performance of Activities. Data User may use and disclose the Limited Dataset only in connection with the performance of the research activities described in Appendix B (Activities). Permitted Access to Limited Dataset. Data User shall limit the use or receipt of the Limited Dataset to the individuals on the research team designated and maintained by the Principal Investigator who need the Limited Dataset for the performance of the Activities. Nondisclosure. Except As Provided In Agreement, Data User shall not use or further disclose the Limited Dataset except as permitted or required by this Agreement and as described in Appendix B. Access to the Limited Dataset by members of the research team who are not affiliated with 91Ů requires the execution of a separate Data Use Agreement between and 91Ů and the external researcher. Identification of Individual. Data User may not use the Limited Dataset to identify or contact any individual who is the subject of the PHI from which the Limited Dataset was created. Disclosures Required By Law. Data User shall not, without the prior written consent of the HIPAA Privacy Officer, disclose the Limited Dataset on the basis that such disclosure is required by law without notifying the Privacy Officer so that 91Ů shall have an opportunity to object to the disclosure and to seek appropriate relief. If 91Ů objects to such disclosure, Data User shall refrain from disclosing the Limited Dataset until 91Ů has exhausted all reasonably available alternatives for relief. Safeguards. Data User shall use appropriate safeguards to prevent use or disclosure of the Limited Dataset other than as provided by this Agreement. Reporting. Data User shall report to the HIPAA Privacy Officer twenty-four (24) hours of Data User becoming aware of any use or disclosure of the Limited Dataset in violation of this Agreement or applicable law. Knowledge of Non-Compliance. Any non-compliance by Data User with this Agreement or with HIPAA or the HIPAA Regulations automatically will be considered a breach or violation of a material term of this Agreement if Data User knew or reasonably should have known of such non-compliance and failed to immediately take reasonable steps to cure the non-compliance. ASSURANCE OF COMPLIANCE WITH DATA USE AGREEMENT It is understood that only study personnel are authorized to receive and use the Limited Dataset described in this Data Use Agreement solely for the purposes described in this Agreement. By indicating his/her agreement, the Principal Investigator acknowledges and agrees that he/she and each of his/her study personnel have reviewed and understand their obligations under this Agreement and will abide by the restrictions on use and disclosure of the Limited Dataset in accordance with this Data Use Agreement. ___________________________________ __________________ Principal Investigator Signature Date This form must be signed and dated in order to be valid. Filing Instructions: Submit a signed and dated copy of this form including Appendix B to  HYPERLINK "mailto:irb@slu.edu" irb@slu.edu. A copy of this signed form should also be retained for your records. Appendix A To qualify for a Limited Dataset, the HIPAA Privacy Rule [45 CFR 164.514(e)] does not permit use of the following direct identifiers of the individual or of relatives, employers, or household members of the individual: (1) Names; (2) Postal address information, other than town or city, state, and zip code; (3) Telephone numbers; (4) Fax numbers; (5) Electronic mail addresses; (6) Social security numbers; (7) Medical record numbers; (8) Health plan beneficiary numbers; (9) Account numbers; (10) Certificate/license numbers; (11) Vehicle identifiers and serial numbers, including license plate numbers; (12) Device identifiers and serial numbers; (13) Web universal resource locators (URLs); (14) Internet protocol (IP) address numbers; (15) Biometric identifiers, including finger and voice prints; and (16) Full face photographic images and any comparable images. 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