EXTERNAL DATA REQUEST
PRINCIPAL INVESTIGATOR / PROJECT DIRECTOR
Prefix:
First Name:
Last Name:
Title / Department:
Institution:
Street Address:
City:
State:
Zip Code:
Phone:
Email:
RESEARCH PROJECT INFORMATION
Title of Research Project:
Project Start Date:
Duration:
Research Design:
Data Requested:
Rationale and purpose(s) for which the requested data will be used:
Has the project been reviewed and approved by the institution’s Internal Review
Board (IRB)? (Attach a copy of the IRB approval notice)
YES: NO:
Craven CC External Data Request Form Form Revision: May 2018
ACCESS TO REQUESTED DATA
List all individuals that will have access to the requested data (attach additional pages as necessary).
NAME
TITLE
INSTITUTION
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
DATA REQUESTS MADE TO OTHER INSTITUTIONS
List all other institutions from which data has been requested for this research project.
(attach additional pages as necessary)
INSTITUTION
1.
2.
3.
4.
5.
ACKNOWLEDGEMENT OF PRINCIPAL INVESTIGATOR RESPONSIBILITIES
As Principal Investigator, I agree that:
Any additions to or changes in the research protocol will be submitted to Craven Community College’s
Office of Institutional Research (IE) for prior written approval.
Any issues associated with the use of the requested data will be reported to IE.
I am responsible for safeguarding the requested data and all work products derived from this data for the
duration of the project.
I will permanently safeguard or securely dispose of all requested data once the project is completed.
PRINCIPAL INVESTIGATOR SIGNATURE
DATE:
Craven CC External Data Request Form Form Revision: May 2018
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