You must have JavaScript enabled to use this form. Principal Investigator Name Proposal Title Start Date End Date SPONSOR INFORMATION Sponsor Name Sponsor Contact Name Email Phone Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country USAAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Sponsor's URL DETAILS Please select the type of non-funded agreement you are submitting - Select -Non-Disclosure AgreementData Use AgreementTeaming AgreementMemorandum of UnderstandingEquipment LoanSoftware LicenseOther Agreement/Other License What will be the route of the information disclosure for this agreement? - Select -Not ApplicableOne-wayTwo-way Indicate the receiving party of the one-way information disclosure. - None -Sponsor - SponsorUniversity of Maryland - University of Maryland Is a third party involved in this agreement? - Select -YesNo If "Yes," provide name of the third party. If "Yes," provide the phone number of the third party. If "Yes," provide the email of the third party. If "Yes," provide the complete address of the third party. Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands If "Yes," provide the URL for the third party's website. What is the pathway of the data transfer? - None -Incoming TO UniversityOutgoing FROM UniversityBOTH Incoming and Outgoing OUTGOING from University DO NOT ROUTE THROUGH KR. UM Ventures negotiates Outgoing Data Use Agreements - They are not routed in KR. Discontinue this routing and contact UM Ventures. Otherwise, revise your response to "Incoming" or "Both" and continue. Who will use the data? UM Investigator UM Graduate Student UM Undergraduate Student List the third parties (non-UMD entities or individuals) with whom you will collaborate or share data with. Will the material(s)/data be used in conjunction with other materials received from a third party? - Select -YesNo List other material(s)/data and their providers. How long will the investigators use the material(s)/data e.g., 2 years? Note, this must not be greater than the period of performance. Will sponsored account funds pay for the obtaining/collection of these material(s)/data? - Select -YesNo Provide KFS sponsored account number or KR institute proposal number. Are there physical storage requirements for these data? - Select -YesNo Describe where these data will be physically stored. Ex. laptop, tiCRYPT, departmental servers, etc. Are there costs associated with this storage? - Select -YesNo Provide KFS sponsored account number or KR institute proposal number. Does this agreement - or data set - include Controlled Unclassified Information (CUI)? - Select -YesNo Does this agreement - or data set - include Classified data? - Select -YesNo Does this agreement - or data set - include Criminal Justice data? - Select -YesNo Does this agreement - or data set - include Export/ITAR controlled data? - Select -YesNo Does this agreement - or data set - include Human Subject Related data? - Select -YesNo Does this agreement - or data set - include Public Health Information (PHI)? - Select -YesNo Does this agreement - or data set - include De-identified, including non-PHI data? - Select -YesNo Does this agreement - or data set - include Encrypted data? - Select -YesNo Does this agreement - or data set - include a Limited data set? - Select -YesNo Is this agreement - or data set - subject to Family Educational Rights and Privacy Act (FERPA)? - Select -YesNo Is this agreement - or data set - subject to General Data Protection Regulations (GDPR)? - Select -YesNo What is the purpose of receiving these data? What type of data will be received? List the names and titles of all individuals who will have access to these data. Will the data include European residents’ data? - Select -YesNo Will the data be used and stored on UMD campus? - Select -YesNo What system will be used to protect data on campus? Is there a real or potential conflict of interest in connection with this work involving a University of Maryland employee, as defined by the University of Maryland Policies and Procedures II-3.10(A) or II-3.10(B)? If "Yes," a disclosure form must be completed and submitted in accordance with these procedures. - Select -YesNo Are any export controls, physical or IT security requirements, restrictions on publications, or use of foreign nationals indicated in the solicitation or in discussions with the sponsor? - Select -YesNo Are there technologies involved in this project which are likely to have a military application or other applications which could be considered to have national security implications? - Select -YesNo Will your project involve the shipment of materials outside of the US? - Select -YesNo If "Yes, list the material(s) and destination(s). Will your project require collaboration with any foreign entity? Select oneYesNo If "Yes," list any foreign entity or individual with whom UMD will collaborate in relation to this project. Will this project involve any information which may not be released to the public without sponsor approval? This may include, but is not limited to, sensitive research results, data sets, proprietary information, trade secrets, publications, and export-controlled information. - Select -YesNo Will such information be subject to a nondisclosure agreement or any other agreement authorizing a sponsor or other party to withhold from publication information provided to UM? - Select -YesNo Will this research include using Human Subjects? - Select -YesNo Have you submitted your IRB Application? - Select -YesNo Title used on IRB Application: IRB Approval Date: The IRB application has not yet been submitted, but will be upon sponsor's selection of proposal for funding. Will this research include vertebrate animals? - None -YesNo Have you submitted your IACUC Application? - Select -YesNo Title used on IACUC application: IACUC protocol approval date: IACUC protocol approval number: The IACUC application has not yet been submitted, but will be upon sponsor's selection of proposal for funding.
