Fill - Free fillable Research App W Non Disclosure Forms Fillable (Commonwealth of Massachusetts) PDF form

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606

MASS.GOV/CJIS

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APPLICATIONFORACCESSTOCORIFORRESEARCHPURPOSES

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ProjectInformation

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TitleofResearchProject:_____________________________________________________________________________

OverseeingAgency/Institution(ifapplicable):_____________________________________________________________

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ApplicantInformation

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FirstName: _______________________________________________________ MiddleInitial: _________________

LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________

StreetAddress: _____________________________________________________________________________________

Apt.#orSuite:______________  City:___________________________ State: _________ Zip:________________

PhoneNumber: _____________________________________________________________________________________

EmailAddress:__________________________________________________________________________ ____________

ResearchDirector

Ifdifferentfromaboveindividual.



FirstName: _______________________________________________________ MiddleInitial: _________________

LastName: _______________________________________________________ Suffix(Jr.,Sr.,etc): _____________

StreetAddress: _____________________________________________________________________________________

Apt.#orSuite:______________  City:___________________________ State: _________ Zip:________________

PhoneNumber: _____________________________________________________________________________________

EmailAddress:__________________________________________________________________________ ____________

ApplicationType

 

Typeofapplicationyouaresubmitting: ☐New ☐Renewal*



* Pleasenote,ifthisisarenewalofapreviousapplication,youonlyneedtorespondtothequestionsbelowifthe

informationsinceyourlastapplicationhaschanged.Iftheinformationisthesame,renewalapplicantsonlyneedto

selecttherenewaloptionandsigntheapplication



ApplicationQuestions

1. Statethegeneralobjectiveofthisresearchstudy.___________________ ________________________________

_____________________________________________________________________________________________________

2. Provideadescriptionoftheresearchdesign,samplingmethod,andstatisticalanalysesthatwillbeused.

_____________________________________________________________________________________________________

THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606

MASS.GOV/CJIS



3. StatethetypeofCriminalOffenderRecordInformation(CORI)datathatyouseektouse.

_____________________________________________________________________________________________________

4. StateyourexpectedsourceofCORI. ______________________________________________________________ 

_____________________________________________________________________________________________________

5. IfyouwillbeobtainingCORIfromasourceotherthanDCJIS,includeacontactpersonandinformationforthat

agency.Alsoincludeacopyofanyapprovaldocumentationyouhavealreadyobtained.____________________

_____________________________________________________________________________________________________

6. Statetheexpectedendproductofthisresearch. ____________________________________________________

_____________________________________________________________________________________________________

7. Provideyourresearchtimelineandestimatedenddate.______________________________________________

_____________________________________________________________________________________________________

8. Provideanexplanationofhowtheresearchwillbenefitpublicsafety.___________________________________

_____________________________________________________________________________________________________

9. ProvideadescriptionofhowCORIdatawillbereferencedinthefinalproduct.____________________________

_____________________________________________________________________________________________________

10. ProvideadescriptionofthesafeguardsthatwillbeputinplacetomaintaintheconfidentialityoftheCORIdata.

_____________________________________________________________________________________________________



ApplicationAttachments



Pleaseincludethefollowingwithyourresearchapplication:

1. Acopyofyourresearchproposal.

2. AsignedNon‐DisclosureAgreementfromthePrincipalResearcher/Researcher.



ApplicationAttestation

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Bysigningbelow,Iaffirmthattheinformationcontainedinthisresearchapplicationandins upportthereofistrueand

complete.IfurtheragreethatshouldIbeprovidedwithauthorizationtoaccessCORIforresearchpurposesthatIwill

maintaintheconfidentialityofCORIdataandcomplywithallapplicable

lawsandregulations,includingbutnotlimited

to,M.G.L.c.6,§§167‐178Band803CMR8.00etseq.



___________________________________________________________________ ____________________________

Signature Date



___________________________________________________________________

PrintedName



THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606

MASS.GOV/CJIS



MassachusettsDepartmentofCriminalJusticeInformationServices

IndividualResearcherAgreementofNon‐DisclosureofCORI



Whereas,________________________________ (“Researcher”)isparticipatingasatheRese archerinaresearch

projectthatwillrequiretheuseofandaccesstoCriminalOffenderRecordInformation(“CORI”),and



Whereas,theDepartmentofCriminalJusticeInformationServices(“DCJIS”)hasapprovedsaidresearchproject,and



Whereas,Researcheracknowledgesaccesstoanddissemination

ofCORIissubjecttotheprovisionsofM.G.L.c.6,§§

167‐178Band803C.M.R.2.00etseq.,thatanydisclosureofCORIexceptaspermittedunderthesectionsoflawand

regulationscitedabovecanresultinacriminalfineofuptofivethousanddollars($5,000.00)

foreachoffenseand/orup

tooneyearimprisonmentinjailorhouseofcorrection,inadditiontocivilliabilityfordamagespursuantto§177

includingexemplarydamages,andacivilfineofuptofivethousanddollars($5,000.00)foreachviolation.



Nowtherefore,Researcherherebyagreestothefollowing:



1. ResearchershallnotdiscloseCORItoanyunauthorizedpersonandshalluseCORIonlyaspermittedbyM.G.L.c.

6,§§167‐178Band803C.M.R.2.00etseq.



2. Researchershallnotreproduce,transfer,ormakeavailableCORItoanyindividualunlessDCJIShasapprovedthat

individual

foraccesstoCORI.



3. ResearchershallpreservetheanonymityoftheindividualswhoseCORIissough t,assetforthin803C.M.R.8.04.



4. Bysigningthisagreement,Researcherprovideshis/herconsenttoDCJIStoconductanallavailableCORIcheckof

theResearcher.DCJISshallaccessallavailable

CORI.Thisauthorizationisvalidforoneyearfromthedateofmy

signature. I maywithdraw thisauthorization atany timeby providing written notice of myintent to withdraw

consenttoaCORIcheck.



5. IacknowledgethattheinformationprovidedtoconducttheCORIcheckistrue

andaccurate.



Signedthis__________dayof,20_______.



____________________________________ ______________________________________

ResearcherName(signature)   ResearcherName(print)



_______________________________________ __________________________________________

DateofBirth(MM/DD/YY)    LastSixofSocialSecurityNumber





THE COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY

Department of Criminal Justice Information Services

200 Arlington Street, Suite 2200, Chelsea, MA 02150

TEL: 617-660-4640 | TTY: 617-660-4606

MASS.GOV/CJIS



MassachusettsDepartmentofCriminalJusticeInformationServices

PrincipalResearcherAgreementofNon‐DisclosureofCORI



Whereas,________________________________ (“PrincipalResearcher”)isparticipatingasathePrincipal Researc herin

aresearchprojectthatwillrequiretheuseofandaccesstoCriminalOffenderRecordInformation(“CORI”),and



Whereas,theDepartmentofCriminalJusticeInformationServices(“DCJIS”)hasapprovedsaidresearchproject,and



Whereas,PrincipalResearcheracknowledgesaccess

toanddisseminationofCORIissubjecttotheprovisionsofM.G.L.

c.6,§§167‐178Band803C.M.R.2.00etseq.,thatanydisclosureofCORIexceptaspermittedunderthesectionsoflaw

andregulationscitedabovecanresultinacriminalfineofuptofive

thousanddollars($5,000.00)foreachoffense

and/oruptooneyearimprisonmentinjailorhouseofcorrection,inadditiontocivilliabilityfordamagespursuantto§

177includingexemplarydamages,andacivilfineofuptofivethousanddollars($5,000.00)foreachviolation.



Nowtherefore,PrincipalResearcher

herebyagreestothefollowing:



1. PrincipalResearchershallnotdiscloseCORItoanyunauthorizedpersonandshalluseCORIonlyaspermittedby

M.G.L.c.6,§§167‐178Band803C.M.R.2.00etseq.



2. Principal Researcher shall not reproduce, transfer, or make available CORI to any individual

 unless DCJIS has

approvedthatindividualforaccesstoCORI.



3. Principal Researcher shall preservethe anonymity ofthe individuals whose CORI is sought, as set forth in 803

C.M.R.8.04.

4. Bysigningthisagreement,PrincipalResearcherprovideshis/herconsenttoDCJIStoconductanallavailable

CORI

checkofthePrincipalResearcher.DCJISshallaccessallavailableCORI.Thisauthorizationisvalidforone

yearfromthedateofmysignature.Imaywithdrawthisauthorizationatanytimebyprovidingwrittennoticeof

myintenttowithdrawconsenttoaCORIcheck.



5. Iacknowledgethat

theinformationprovidedtoconducttheCORIcheckistrueandaccurate.



Signedthis__________dayof,20_______.



____________________________________ ______________________________________

PrincipalResearcherName(signature)    PrincipalResearcherName(print)



_______________________________________ __________________________________________

DateofBirth(MM/DD/YY)    LastSixofSocialSecurityNumber



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Research App W Non Disclosure Forms Fillable (Commonwealth of Massachusetts)

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