1 DUA Supplement

HRSA Data Use Agreement Supplemental Form: Study Overview

Date of Submission
Lead Investigator Name & Title
Requesting Organization
Study Title
Study Funding Source(s)
Proposed Study Start Date
Data Files & Years Requested
Statistical Package(s) to be Used

Study Description | Project Staff | Data Management Plan | Reporting and Dissemination of Findings

1. STUDY DESCRIPTION

1. Study Overview: Describe your study aims and objectives. As applicable, include study purpose, hypotheses, goals, research questions, and public health benefit (maximum word length: 200).

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2. Data Files

   1. Justification: Explain why you requested each data file for the study analysis.

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2. Variable List Requested: List the data file variables you are requesting and explain how you will use them.

Variable Name	Variable Label/Description	How Will You Use the Variable in Your Study?

** Add more rows as needed.

3. Non-HRSA Files: List any non-HRSA files you are planning to use in conjunction with the above files for your analysis and provide a general description of the data (e.g., file name, year, source). Explain why you need to use non-HRSA files for this study. Type “N/A” in the space below if not applicable.

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4. Merge Procedures: Describe any merge procedures you intend to use to produce each dataset for your study.

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1. If applicable, list the variable(s) you will use to merge any non-HRSA data files with the data files you are requesting under the DUA.

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2. If applicable, list the variable(s) you will use to merge HRSA public use data files with the data files you are requesting under the DUA.

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3. Methodology: Describe what analytic procedure(s) or model(s) you will use (e.g., descriptive statistics, logistic regression, log-linear modeling). For each procedure or model, specify the unit of analysis and any subpopulations.

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2. PROJECT STAFF

This section specifically identifies project staff, their organizational affiliations, and projected roles in this study. All individuals with access to raw data, analytic files, or output with cell sizes less than 50 must be included in this list and must sign the DUA. In addition, students must list their faculty advisor as a project staff member, and the faculty advisor must also sign the DUA.

Name
Title
Organization
Role in this Study
Email Address
Phone Number (include area code)
Mailing Address (include street address, city, state, and zip code)
US Citizen? (specify YES or NO)

Name
Title
Organization
Role in this Study
Email Address
Phone Number (include area code)
Mailing Address (include street address, city, state, and zip code)
US Citizen? (specify YES or NO)

Name
Title
Organization
Role in this Study
Email Address
Phone Number (include area code)
Mailing Address (include street address, city, state, and zip code)
US Citizen? (specify YES or NO)

Name
Title
Organization
Role in this Study
Email Address
Phone Number (include area code)
Mailing Address (include street address, city, state, and zip code)
US Citizen? (specify YES or NO)

** If more individuals need to be added to this section, please copy and paste above fields.

3. DATA MANAGEMENT PLAN

1. Storage, Protection, and Sharing

   1. Provide name(s) and job title(s) of all individuals who will have primary responsibility for organizing, storing, and archiving study data.

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2. Explain how your organization will notify HRSA of any study staffing changes.

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3. Describe the physical and technical safeguards your organization will use to protect HRSA data files (e.g., password protocols, log-on/log-off protocols, session time out protocols, data encryption).

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4. Explain how your organization will notify HRSA of any suspected incidents where the security and privacy of HRSA data may have been compromised.

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5. Describe how your organization will respond to potential breaches in the security and privacy of HRSA data.

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6. Describe how you will share, transmit, and distribute HRSA data files within your organization.

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7. Are additional organizations involved in analyzing the data files provided by HRSA? Yes/No

IF YES: Indicate how these organizations’ analysts will access the data files.

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2. Data Disposal

   1. Describe your plan to notify HRSA when the study is complete and use of the data is no longer needed.

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2. Describe your plan to properly dispose of data files and ensure they will not be used following completion of the study.

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4. REPORTING AND DISSEMINATION OF FINDINGS

1. Dissemination of Findings: Describe all of your plans to disseminate the findings from your study, including specific media through which you will report results (e.g., internal report, external white paper, publication in a peer-reviewed journal, presentation at a scientific meeting, etc.).

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2. Examples/Table Shells: If available, include examples of table shells, models, and/or graphs. Please also indicate the subsample or unit of analysis used in each type of table, model, or graph.

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Signature of Lead Investigator	Date

Public Burden Statement: 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. The OMB control number for this project is 0906-xxxx. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N-39, Rockville, Maryland, 20857.

OMB #0906-xxxx Expiration xx/xx/xxxx 6