Attach 11_Collaborator_Confidentiality

Attachment 11: Collaborator Confidentiality Agreement

AGRICULTURAL HEALTH STUDY

REQUEST FORM

Type of Request:

[ ] Data Request (complete sections A, B, and C)

[ ] Collaboration Request (complete sections A and B)

Section A

Name of Requester:

Date of Request:

Date Needed (allow time for approval signatures and data processing):

Phone Number of Requester:

E-Mail Address:

Tentative Manuscript Title:

Proposed Journal Article will be submitted to:

Lead Investigator:

(First Author)

(Institutional Affiliation)

Collaborators: (Secondary Authors)

Name (Print)		Initials/Signature

For Coordinating Center Use Only	Request No.
	Date data sent:		Initials:

Section B

Brief Narrative Description of Proposed Research:

Purpose:

Methods:

Section C

Specific Data Items Requested

Phase I

[ ] Private Applicator File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Commercial Applicator File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Spouse File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Female and Family Health File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Other (specify data set)

Selection Criteria:

No. of variables requested:

File containing variable list*:

Phase II

[ ] Private Applicator File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Commercial Applicator File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Spouse File

Selection Criteria:

No. of variables requested:

File containing variable list*:

[ ] Other Files (specify) ________________________________________________________________

Selection Criteria:

No. of variables requested:

File containing variable list*:

Output format:

[ ]	SAS (preferred-specify PC or Unix)
[ ]	Comma Delimited
[ ]	ASCII Column Delimited

Format in which data is to be sent:

[ ]	Diskette/CD-ROM
[ ]	Paper copy (if output is less than 60 pages)
[ ]	Internet (Secure FTP only)

You may complete and return the remainder of the Request Form by email, but we must receive the signed Pledge of Confidentiality by fax. Please fax the signed Pledge of Confidentiality to Ben Laimon at 301.294.2085. Be sure to include your printed name and the title of the project.

Pledge of Confidentiality for Collaborators

Prior to receiving AHS data it is required that collaborators review and sign the following pledge of confidentiality.

I hereby certify that I will keep completely confidential all information arising from Agricultural Health Study data concerning individual respondents to which I gain access. I also certify that I will abide by all requirements of the NCI Institutional Review Board (IRB) and other applicable IRBs. Beyond the research team, I will not discuss, disclose, disseminate, or provide access to survey data and identifiers except as authorized in writing by the Agricultural Health Study Executive Committee. I shall use the Agricultural Health Study data only for approved purposes. I am also aware that I am responsible for the compliance of all other personnel under my supervision who have access to the data provided to me by the AHS. I agree to report any breaches in confidentiality to the Executive Committee within 24 hours of their being discovered. I give my personal pledge that I shall abide by this assurance of confidentiality.

Name (Signature) _______________________________________ Date _________________

Name (Print) ______________________________________

Project Title: ______________________________________

Mailing Address (This should be a street address so that Federal Express will deliver to it):

Address 1______________________________________

Address 2______________________________________

City___________________________________________

State__________________________________________

Zip____________________________________________

Section D

Approval:

		Date:
	Michael C. R. Alavanja, Dr. P.H., Project Officer
		Date:
	Laura Beane-Freeman, Ph.D.
		Date:
	Dale P. Sandler, Ph.D.
		Date:
	Jane Hoppin, Sc.D.
		Date:
	Kent Thomas

DRF9 -2- 11/2007