<p> Independent “Honest Broker” Assurance Agreement</p><p>Study Title: IRB#: PRO</p><p>Principal Investigator (PI): </p><p>To be completed by the individual who is de-identifying the data (NOT the PI)</p><p>Name: Position: </p><p>Email: Phone: Honest Broker #: HB</p><p>Name of Honest Broker System/Process: </p><p>Additional Comments: </p><p>By signing below, I agree/certify that:</p><p>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. </p><p>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. </p><p>3. I will not intervene or interact with identified human subjects during the conduct of this research project.</p><p>4. I will maintain complete confidentiality of research subjects’ private information.</p><p>______Signature Date</p><p>______</p><p>University of Pittsburgh .Human Research Protection Office . 3500 Fifth Avenue . Phone 412-383-1480 . www.hrpo.pitt.edu v. 1.30.2016 1of 1</p>