Note: This data request form has been adapted from Data Request Form used by the National Institute of Diabetes 
and Digestive and Kidney Diseases within the National Institutes of Health. 
CERC-SON-UVI 
 
DATA USE REQUEST FORM 
CARIBBEAN EXPLORATORY RESEARCH CENTER 
SCHOOL OF NURSING 
UNIVERSITY OF THE VIRGIN ISLANDS 
 
Please complete this form to request the use of one or more datasets from the UVI-SON-CERC data 
repository. Requests should be sent via email to the Interim CERC Director, at nmichae@uvi.edu.   
 
* = Required Field 
 
Data Request 
 
Request Name* (ex: Research Project on CERC Data) 
 
Create a nickname for your reference. 
 
Requestor Information 
 
 
Full Name* 
Physical and/or Mailing Address* 
 
Email* 
 
 
Title (ex: Undergraduate Student) 
Name of Institution 
 
Phone (ex: 123-456-7890) 
For students(graduate/undergraduate): 
 
Advisor’s Full Name* 
Advisor’s Email Address* 
 
 
 
 
 
  
 
 
 
 
 
Note: This data request form has been adapted from Data Request Form used by the National Institute of Diabetes 
and Digestive and Kidney Diseases within the National Institutes of Health. 
CERC-SON-UVI 
 
Support Information 
 
 
Support Type (ex: Funding Award, MOA, MOU) 
Other 
 
Grant/PAR Number 
 
Request Details 
 
 
Study* 
 Describe CERC study data being requested (IPV, YRBS, HSRP-VI, etc) 
 
Information Security: Please check the information security practices to be used. 
 
Institute supported, controlled access server. 
 
Institute supported, password protected, desktop computer. 
 
Encrypted, password protected laptop computer. 
Encrypted portable media (encrypted external hard drive, encrypted thumb drive) 
Unencrypted portable media backup (CD, DVD, thumb drive) stored in locked file cabinet. 
Study data must be maintained in a secure and controlled environment. 
 
 
 
 
Note: This data request form has been adapted from Data Request Form used by the National Institute of Diabetes 
and Digestive and Kidney Diseases within the National Institutes of Health. 
CERC-SON-UVI 
 
Comments 
Discuss how data security will be ensured (protocols installed on computer/s to be used) to meet HIPAA data security. Also 
indicate who else will have access to the data that is being requested for use. 
 
 
 
Agreement Form 
 
 
Title of Research Plan* 
 
 
Other Users* 
Provide names and institutional affiliation and role in proposed research study.  
 
Requested Materials*(Name of Data Set)
 
Note: This data request form has been adapted from Data Request Form used by the National Institute of Diabetes 
and Digestive and Kidney Diseases within the National Institutes of Health. 
CERC-SON-UVI 
 
Description of Research 
Describe research to be conducted and key variables from dataset that will be used to support proposed research. 
 
 
 
Research Objectives and Design* 
Describe research design, research questions and/or research objectives as well as hypotheses to be tested, if any. 
 
Analysis Plan* 
Describe data analysis to be completed to answer research questions and/or test hypotheses. 
 
 
 
 
 
Note: This data request form has been adapted from Data Request Form used by the National Institute of Diabetes 
and Digestive and Kidney Diseases within the National Institutes of Health. 
CERC-SON-UVI 
 
Public Use Statement* 
This statement may be used by UVI-SON-CERC to describe how CERC data sets are used by various researchers. 
 
 
Please include a one-two (1-2) paragraph statement which may be made publicly available. Include information about the 
intended audience for the research results and the benefits to the participants and/or community or to the advancement of 
science.