ÁùºÏ±¦µä

Entity Requesting Data (AKA: Data Recipient)

Receiving Institution Name:
Data Recipient Name and Title:
Address:
Email:
Phone:

Entity Providing Data (AKA: Data Provider)

Providing Institution Name:
Contact Name and Title:
Address:
Email:
Phone:

1. This Agreement applies to the following (select one):
   1. Limited Data Set involving Protected Health Information
   2. Other research data/information, describe:
2. This Agreement sets forth the terms and conditions pursuant to which the Data Provider will Disclose the following to the Data Recipient:
   List of Data to Be Disclosed (AKA: Data Set):
3. Except as otherwise specified herein, Data Recipient may make Uses and Disclosures of the Data Set consistent with the purpose of the research as described in the application for the following research project:
   Title of Research Project:
4. In addition to the Data Recipient, the individuals, or classes of individuals, who are permitted to use the Data Set for purposes of the Research Project, include:
   Researcher Names:
5. Data Recipient agrees to not Use or Disclose the Data Set (or components) for any purpose other than as described for the Research Project or as Required by Law.
6. Data Recipient agrees to use appropriate safeguards to prevent Use or Disclosure of the Data Set (or components) other than as provided for by this Agreement.
7. Data Recipient agrees to ensure that any agent, including a subcontractor, to whom it provides the Data Set, agrees to the same restrictions and conditions that apply through this Agreement to the Data Recipient with respect to such information.
   Subcontractor Names:
8. Data Recipient agrees to report (within ten (10) days of discovery) to the University any Use or Disclosure of the Data Set (or components) not provided for by this Agreement, including without limitation, any Disclosure of the Data Set (or components) to an unauthorized subcontractor.
9. Data Recipient agrees not to contact any individuals from or about whom the data apply, and for Limited Data Sets, agrees not to attempt to identify the information contained in the Data Set.
10. Data Recipient will indemnify, defend and hold harmless the University’s and any University affiliates’ trustees, officers, directors, employees and agents from and against any claim, cause of action, liability, damage, cost or expense (including without limitation, reasonable attorney’s fees and court costs) arising out of or in connection with any unauthorized or prohibited Use or Disclosure of the Data Set or any other breach of this Agreement by Data Recipient or any subcontractor, agent or person under Data Recipient’s control.

Signatures

University of ÁùºÏ±¦µä, Reno Signatory Official External Institution Signatory Official
Sponsored Projects/0325
University of ÁùºÏ±¦µä, Reno
1664 North Virginia Street
Reno, NV 89557
775-784-4040

Signature:
Printed Name:
Title: