Independent Honest Broker Assurance Agreement

Independent “Honest Broker” Assurance Agreement

Study Title: IRB#: PRO

Principal Investigator (PI):

To be completed by the individual who is de-identifying the data (NOT the PI)

Name: Position:

Email: Phone: Honest Broker #: HB

Name of Honest Broker System/Process:

Additional Comments:

By signing below, I agree/certify that:

1. I have reviewed this project with the Principal Investigator (PI) and agree to de-identify and, if applicable, to maintain linkage code information for data / specimens that will subsequently be accessed by the research team.

2. I will, under no circumstance, provide the PI or any member of the research team with information that would permit the identification of research subjects.

3. I will not intervene or interact with identified human subjects during the conduct of this research project.

4. I will maintain complete confidentiality of research subjects’ private information.

______Signature Date

______

University of Pittsburgh .Human Research Protection Office . 3500 Fifth Avenue . Phone 412-383-1480 . www.hrpo.pitt.edu v. 1.30.2016 1of 1