Form 2 NCS Vanguard Data Request Form

The National Children’s Study Vanguard Data
Request Form
* = Required Field

OMB# xxxx-xxxx
exp. date xx/xx/xxxx

Request Identifier
Request Name *

Create a brief title for your research plan

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 (xxxx-xxxx). Do not return the
completed form to this address.
Privacy Act Notification: Information collected as part of the data use agreement, data request forms, and
distribution agreement may be made public in part or in whole for tracking and reporting purposes. This
Privacy Act Notification is provided pursuant to Public Law 93-579, Privacy Act of 1974, 5 U.S.C. Section
552a. Authority for the collection of the information requested comes from the authorities regarding the
establishment of the National Institutes of Health, its general authority to conduct and fund research and to
provide training assistance, and its general authority to maintain records in connection with these and its
other functions (42 U.S.C. 203, 241, 289l-1 and 44 U.S.C. 3101), and Section 301 and 493 of the Public
Health Service Act. These records will be maintained in accordance with the Privacy Act System of Record
Notice 09-25-0200 (https://oma.od.nih.gov/forms/Privacy%20Documents/PAfiles/0200.htm) covering
“Clinical, Basic and Population-based Research Studies of the National Institutes of Health (NIH), HHS/NIH/
OD.” The primary uses of this information are to document, track, and monitor and evaluate the submission
of data from clinical, basic, and population-based research activities and to notify Submitters in the event a
potential error in the dataset is identified or in the event of updates or other changes to the database. The
Federal Privacy Act protects the confidentiality of the Submitter’s NIH records. The NIH will use the
information collected for the purposes described above. In addition, the Act allows the release of some
information in the Submitter’s records without the Submitter’s permission; for example, if it is requested by
members of Congress or other authorized individuals. The information requested is voluntary, but necessary
for obtaining access to data and samples in the NCS Archive.

Requesting Investigator Information
Name *

Address *

Title

Institution

Email *

Phone *

Department

Fax

Website

Recipient Information
Institution type *

Number of years in scientific research

Non-Profit Organization

0-5

Commercial Organization

5 -10

Academic

10+

Government

Is fundingcurrentlyavailable for this
research? *
Yes
No
If yes, please upload
documentation of primary funding

Approximately how many years has the lead investigator been involved in
scientific research?
If no and funding is not yet available,
please indicate anticipated primary
funding source
NIH Intramural Research
NIH Extramural Research
Non-NIH Federal Funding
Private Foundation
Funding Outside of United
States
Industry
Institutional/Departmental
State Funding
Pending
No Direct Funding or Not
Applicable

Request Details
Subject Characteristics

Describe the characteristics of the subjects to be searched for available data. 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

Email

Approved User #1 Name

Approved User #1 Email

Name

Email

Approved User #2 Name

Approved User #2 Email

Name

Email

Approved User #3 Name

Approved User #3 Email

Name

Email

Approved User #4 Name

Approved User #4 Email

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
Comments

Upload Checklist
I have uploaded institutional sign off or a cover letter approving research
I have uploaded documentation of primary funding