Form 10040 (12/07) 10040 (12/07) PREDICT Referring Letter

OMB # 1640-0012 / Expires 12/31/2013

PREDICT
REFERRING LETTER

READ THESE INSTRUCTIONS CAREFULLY
BEFORE PROCEEDING
Thank you for your interest in joining the PREDICT community.
All Researchers must have an account to request PREDICT datasets. A Researcher may be a Principal
Researcher or it may be a Research Organization. All Researchers must submit a Referring Letter from
the organization with which they are aligned or affiliated. The following definitions are important.
Principal Researcher shall mean a researcher who requests PREDICT datasets in an individual capacity
and who has been identified by a Referring Organization as someone who has a legitimate need for the
data.
Referring Organization shall mean an entity that identifies a Principal Researcher as someone who is
affiliated or aligned with the Referring Organization and who has a legitimate need for PREDICT
datasets.
Research Organization shall mean an organization that desires to have research conducted on its behalf
and designates individuals as Data Custodians to request and be responsible for PREDICT datasets.
Data Custodian shall mean the person designated by a Research Organization as responsible for
requesting PREDICT datasets for a research effort and ensuring that the organization’s responsibilities for
the receipt, security, oversight, and handling of the Data are met.
Registering as a Principal Researcher or Research Organization
Two primary considerations are important when deciding whether to register as a Principal Researcher or
as a Research Organization: (1) whether the individual or the organization is legally bound to terms and
conditions regarding the use of the data that are set forth in a memorandum of agreement (MOA) between
the Researcher and the PREDICT Coordinating Center (PCC), and (2) whether responsibility for the data
may be transferred from one person to another (allowed for Research Organization, not allowed for
Principal Researcher). Please refer to the diagram on page 3, which illustrates the relationships
between Researchers, the Referring Organization, and the PCC.

DHS Authority to Collect This Information:  The Homeland Security Act of 2002 [Public Law 107‐296, §302(4)] authorizes the Science and Technology Directorate to 
conduct “basic and applied research, development, demonstration, testing, and evaluation activities that are relevant to any or all elements of the Department, 
through both intramural and extramural programs.” In exercising its responsibility under the Homeland Security Act, S&T is authorized to collect information, as 
appropriate, to support R&D related to improving the security of the homeland. Principal Purpose:  DHS collects name, organization and title (if any), email address, 
home and/or work address, and telephone numbers for the purpose of contacting individuals regarding the PREDICT project and/or their involvement with PREDICT. 
Routine Uses and Sharing:  Some of your information will be disclosed to PREDICT team members, such as data hosts, data providers, PREDICT contractors, the 
Predict Coordinating Center, the advisory board, and review board members to help us deliver requested PREDICT services and operate the PREDICT Web site and 
deliver the services you have requested. Unless you consent otherwise, this information will not be used for any purpose other than those stated above. However, 
DHS may release this information for an individual on a case‐by‐case basis as described in the DHS/ALL‐002 System of Records Notice (SORN), which can be found 
at: www.dhs.gov/privacy. Disclosure:  Furnishing this information is entirely voluntary; however, failure to furnish at least the minimum information required to 
register (to include full name and email address,) will prevent you from obtaining authorization to access system.  
PRA Burden Statement: A U.S. Government agency may not conduct or sponsor an information collection and a person is not required to respond to this 
information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1640‐0012 and this 
form will expire on 12/31/2013. The estimated average time to complete this form is 60 minutes per respondent. If you have any comments regarding the burden 
estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC 20528. 

DHS Form 10040 (12/07)

Page 1 of 4

Last Update: 9-8-11_v1.0

A Principal Researcher is personally responsible for the PREDICT data that he/she is approved to use.
A Principal Researcher must have a Referring Organization submit a letter to the PCC confirming that the
Researcher is affiliated or aligned in some manner with the Referring Organization and has a legitimate
need to use the PREDICT datasets. A Principal Researcher may involve others in the R&D project that
he/she plans to lead using PREDICT data, but the other R&D “team members” do not need a Referring
Letter. If the Principal Researcher is no longer affiliated or aligned with the Referring Organization or the
research project, or dies, access to the datasets must cease immediately. Someone from the research team
or a new person may apply to become the new Principal Researcher to use the datasets.
A Referring Letter may specify more than one Principal Researcher who seeks to use PREDICT data. For
example, Sample University may have three Principal Researchers who lead research projects and who
want to use PREDICT datasets in their work. Sample University may submit one Referring Letter and list
all three on the Letter.
A Research Organization must submit a Referring Letter on behalf of itself and designate a person to
serve as its Data Custodian for each research initiative that uses PREDICT data. A Referring Letter may
specify more than one Data Custodian. For example, Sample Entity may have five researchers who lead
research projects on behalf of Sample Entity. Sample Entity may list all five lead researchers as Data
Custodians on the Letter. If a Data Custodian leaves the Research Organization, or the research project, or
dies, the Research Organization must notify the PCC and may nominate a new Data Custodian. Upon
approval, the PCC may transfer access to the datasets to the new Data Custodian.
Although the Referring Letter is not a legally binding document, all Referring Letters must be signed by a
person who has authority to act on behalf of the organization and sign legal documents. It may not be
signed by the Principal Researcher or Data Custodian, even if they possess such authority.

QUESTIONS OR NEED ASSISTANCE?
Please contact the PCC for assistance or questions at +1 800 957 6422 (USA) or via email at [email protected].
INSTRUCTIONS FOR ALL APPLICANTS
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Please put the text of the Referring Letter below on the Referring Organization’s letterhead.
Fill in appropriate names, dates, and other requested information; do not omit any of the
information, as incomplete letters will delay the process.
Do not use abbreviations for organization names, schools, departments, etc.
Add as many lines in the table as you need to include all names.
Please scan and send the signed letter to the PCC at [email protected] or fax it to +1 866
835 0255. The PCC will respond to the Referring Organization within one week from receipt.

Page 2 of 4

Last Update: 9-8-11_v1.0

Date
RTI International
PREDICT Coordinating Center
Attn: Project Manager
P.O. Box 12194
Research Triangle Park, NC 27709-2194
SUBJECT: Referring Letter for Access to PREDICT Data
Dear PREDICT Coordinating Center:
I am sending this Referring Letter for Researcher access to PREDICT data. This letter is (check one):
Referral of Principal Researcher(s).
Full Name of Researcher

Address

Title

Email

Phone

The above named person(s) have a legitimate need for PREDICT data, owing to their position within this
organization and/or the responsibilities assigned to them. I hereby confirm that the above individual(s) is/are
currently affiliated or aligned with this organization, is/are in good standing, and serve in the capacity noted above.
I, or any successor in my role, will inform the PCC if any of the above named individual(s) leaves our organization
or are no longer leading the research effort using PREDICT data, and I will ensure that access to the PREDICT data
ceases.
Referral of Entity as Research Organization, listing one or more Data Custodians.
Full Name of Data Custodian

Address

Title

Years
With Org

Email and
Phone

This organization desires to use PREDICT data as a Research Organization. The above named person(s) have a
legitimate need for PREDICT data, owing to their position within this organization and/or the responsibilities
assigned to them. I hereby confirm that the above named individual(s) will serve as Data Custodian(s) for PREDICT
datasets used by this organization and are trusted by us to be responsible for PREDICT data and research efforts on
behalf of this organization. I, or any successor in my role, will inform the PCC if any of the individual(s) named
above as a Data Custodian is/are no longer in that role. At the same time, we will provide information on the Data
Custodian(s) we propose to replace the previous one(s).
I understand that a Referring Letter must be signed by a person who has authority to act on behalf of the Referring
Organization. I have such authority.

Sincerely,
Signature

Address

Name (Printed or Typed)

City, State/Province/Zip

Title or Position

Email

Date (MM/DD/YYYY)

Telephone