Attachment A.2 Vanguard Data Request Form

A.2 Vanguard Data Request Form OMB# 0925-XXXX

XX/XX/2015

National Children’s Study Vanguard Data Request Form

* = Required Field

Request Identifier

*Project Name:

Create a nickname for your reference.

Requesting Investigator Information

*Name:

*Address:

Title:

*Institution:

*Email:

*Phone:

Department:

Fax:

Website:

Recipient Information

*Institution type:

• Non-Profit Organization

• Commercial Organization

• Academic

Number of years in scientific research:

• 0-5

• 5-10

• 10+

Approximately how many years has the lead investigator been involved in scientific research?

*Is funding currently available for this research?

• Yes

• No

If yes, please upload documentation of primary funding:

Upload Documents:

If funding is not yet available, please indicate anticipated primary funding source.

–Upload Documents

Request Details

Subject characteristics:

Describe the characteristics of the subjects to be searched for available specimens. Criteria might include gender, age, disease status, genotype, etc. Be as specific as possible.

*Research Plan, describe this request, including a summary of the rationale, main hypothesis and proposed research aims:

A brief overview of your research needs.

Scientific background and rationale:

Provide the research protocol background, objectives and hypothesis.

Approved Users Name and email:

1.

2.

3.

4.

*Information Security: Please
check the information security
practices to be used:

• Institute supported, controlled access server

• Institute supported, password protected desktop computer

• Encrypted, password protected laptop computer

• Encrypted portable media (encrypted external hard drive, encrypted thumb drive)

• Unencrypted portable media backup (CD, DVD, thumb drive) stored in locked file cabinet

Study data must be maintained in a secure and controlled environment

Upload Institutional sign off or cover letter approving research

Comments:

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0647). Do not return the completed form to this address.