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SDSU HealthLINK Center for Transdisciplinary Health Disparities Research

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Server Intake Form

Project Information

Note:

Turnaround time is 7 days

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Primary Investigator Name *

First

Last

Phone Number

Email *

Department or Community Organization *

Location *

HealthLINK Center Project Name

Grant Number or Identifier

In a few sentences, summarize the purpose of your project: *

Funding Information

Are you currently seeking funding? *

Yes
No

What type? *

Extramural
Intramural
Extramural and Intramural

From which agency are you seeking funding? *

Specify Agency: *

When is the due date of your proposal? *

Have you already acquired funding? *

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No

From what Agency did you acquire funding? *

Specify Agency: *

Do you already have an IRB approval?

Yes
No

Status of Your IRB Submission: *

In Development
Pending Review
Approved

Protocol Number from InfoEd: *

Please provide the link of the RFA associated with your funding if available:

Data Protection Level

https://www.hipaajournal.com/considered-phi-hipaa

Will you be storing data that is considered Protected Health Information under HIPAA (Health Insurance Portability and Accountability Act of 1996)? *

Yes
No

Click here for Data Protection Level definitions. (opens in separate page)

What is the highest level of protection for the data you will store in the requested server based on the definition/examples of data protection level provided below?

PL-1
PL-2
PL-3

Operating System

MacOS
CentOS Linux
Ubuntu Linux
Windows

Desired machine name

(e.g., “machine name”.sdsu.edu)

General comments:

I agree to abide by the terms and conditions established in the SDSU Information Security Plan

SDSU Information Security Plan

Name

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Research Centers in Minority Institutions

The SDSU HealthLINK Center is supported by the National Institute on Minority Health and Health Disparities, part of the National Institutes of Health, under Award Number U54MD012397; additional support is provided by S21MD010690 (SDSU HealthLINK Endowment). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.