3 Integrated Canine Data Commons (ICDC) Data Sub Form

Attachment 4: ICDC Data Submission Request Form

OMB No.: 0925-0775
Expiration Date: 06/30/2025

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing at any time. Refusal to participate will not affect your benefits in any way. The information collected will be kept private to the extent provided by law. Names and other identifiers will not appear in any report. Information provided will be combined for all participants and reported as summaries. You are being contacted online to complete this form so that NCI can consider your study for submission into the Integrated Canine Data Commons.

Public reporting burden for this collection of information is estimated to average 30 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 (0925-0775). Do not return the completed form to this address.

Please complete the following document and send to: icdchelpdesk@mail.nih.gov. Please include a narrative describing your study and its scientific benefit for inclusion in the ICDC.

Please include the following information along with the narrative:

1. Name/Identifier of Study

2. Grant ID and funding source (if applicable)

3. IACUC/IRB approval numbers (if applicable)

4. Scientific Point of Contact (Name, Phone, Email)

5. Data Manager Point of Contact (Name, Phone, Email)

6. Data access policy (choose one): Open-access – no-embargo, Controlled-access – no embargo, Open-access – embargo, Controlled-access - embargo

7. Cancer type(s) included in study

8. Number of subjects included in study

9. Sample Source (e.g., CCOGC, other biospecimen repository, self-collected) - if other than self-collected, those identifiers will be required during submission

10. If self-collected, was a replicate sample also submitted to another biospecimen repository (e.g., CCOGC). If so, those identifiers will be required during submission.

11. Data types included in study (check all that apply): Imaging, genomics, proteomics, immunology, clinical, other (specify)

12. Amount of data (in TB)

13. The overall scientific benefit of including this study in the ICDC prototype

14. Any publications associated with this study, if any

15. Time constraints on processing/loading/releasing the data

16. Data standards used, if any (e.g., SEND)

17. Anticipated budget needed to prepare data set for submission

Please attach (if available):

1. Data Dictionary specific to study

2. Data Model/Schema diagram indicating how collected data relates to subjects, visits, samples, etc.

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