IRB Application Form for Secondary Data Analysis

Project Information

Project Title Principal Investigator Name PI Email PI Affiliation

Secondary Data Source

Describe the data source How was access to the data obtained? Is the data de-identified? Yes No If not, what identifiers are included?

Research Description

Describe the purpose of your study Summarize the methods/analysis plan Describe any risks to subjects Describe any potential benefits

Data Security

Describe how the data will be stored and protected Who will have access to the data?

Additional Information

Was the original study IRB-approved? Yes No Unknown Describe measures for maintaining confidentiality Other relevant information