ࡱ> O bjbjgQgQ M;e;e F F 8[])''"III:$%((((((($ ,.(9"99(II\(6U!U!U!9RII@'pU!9(U!U!:%,,&I'x{j% ,'!)<])%.w/*w/,&w/,&99U!99999(( 6999])9999w/999999999F Q: UHREB Waiver Request Secondary Use of Data Please submit one electronic copy to the University Human Research Ethics Board (UHREB) c/o Ethics Program Officer, Research Implementation, Ethics and General Information Date: ______ Name of person(s) submitting application: ______ Title of project: ______ Department(s): ______ E-mail addresses: ______ Category of Researcher: __Faculty __Research Associate __Graduate Student - Program of Study/Degree (please specify): ______ __ Undergraduate Student __Other (please specify): ______ The project for which this data was originally collected has already been reviewed by __External agency (please specify): ______ __ Research Ethics Board (please specify): ______ __Third party: (e.g., school board, hospital, etc.) (please specify): ______ Attach a copy of the approval (s) if available. If not, please explain the approval process. Under what ethical guidelines did the original data collection take place?: ______ Funding/Sponsorship Has this project received funding (internal or external): __Yes or __No If yes, please indicate the source of funding: _ _ Agreement: I/we have read the University Human Research Ethics Board (UHREB) Guidance Document 1 Undertakings Requiring Review, and Guidance Document 3 Procedures Related to Faculty Research and Graduate Student Research, and the most recent version of Tri-Council Policy Statement on the Conduct of Research Involving Humans (TCPS2) and agree to comply with the policies and procedures outlined therein. In the case of student research, as Faculty Supervisor, my signature further indicates that I have read and approved the application and proposal, deem the project valid and worthwhile, and agree to provide continuing and thorough supervision of the studen. Signatures: For Faculty/Staff Research Projects Signature(s) of Investigator(s): Date: For Student Research Projects Signature(s) of Student Investigator: Date: Signature(s) of Faculty Supervisor(s) Date: Shaded area for UHREB/ Associate Vice-President, Research and Innovation Office onlyApproval date:Approved signature: Were the data originally collected for the purpose of creating a dataset for subsequent use by researchers? Yes/No If so, please identify the source of the dataset and provide a URL for an organizational website describing the dataset where available. (Max page)  If not, briefly describe the purpose of the original study. Please attach the consent form used when collecting the original data (if applicable and available). (Max page)  What is the purpose and rationale of the proposed research? Be sure to explain how the proposed research differs from the original research, if applicable. Also indicate whether the purpose of the proposed research differs from what the participants originally gave consent to in the informed consent process, and, if so, how. (Max 1 page)  Describe the data you will be using and how (e.g., reviewing videotapes/transcripts or analyzing a dataset). (Max page)  Please describe how you obtained access to the data.  Data Linkage Will the research involve linking data sets (i.e., using data collected from multiple sources)?  Yes  No If so, how?  Indicate the amount of identifying information in the data: Has the data had identifying information removed and replaced with a code? (The applicant does not have access to the code.)  Yes  No b) Is the data anonymized either by being stripped of identifying information or by never having contained identifying information?  Yes  No c) Does the data contain identifying information on participants?  Yes  No d) Does the data contain a code or other information that could potentially be used to establish the identity of participants?  Yes  No e) If yes, could participants identities be established through data linkage?  Yes  No Please Note: If the data fall into categories a) or b), only the above questions need to be addressed. If the data fall into categories c), d), or e), you must submit a completed application for ethics approval to your Departmental/Faculty Ethics Committee and, if applicable, to the UHREB.     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