Project Title Lead Researcher Name Email Address Department/Organization Date of Submission

Brief Summary of the Project Description of Secondary Data to be Used Source of Data Do you have permission to use this data?
(Please describe.)

Does the data contain personal or sensitive information? Yes No Unsure If yes, has the data been de-identified or anonymized? Yes No Not Applicable Describe any steps taken to protect privacy and confidentiality:

Potential Risks to Participants Risk Mitigation Strategies

Data Storage and Security Arrangements Plans for Data Destruction/Retention

Other Relevant Information