Declaration of ConsentI, the undersigned, understand that the ATR Network-BMI Consortium requires thatthe following Data Use Terms be signed, submitted and approved before applicants may
receive access to the Network-BMI Brain Database generated by the Network-BMI
Project (NBP; supported by a contract with Japan’s Ministry of Internal Affairs andCommunications (MIC) entitled, ‘Novel and innovative R&D making use of brain structures’).
I hereby give consent to the following terms of use of the Network-BMI Brain Database(hereinafter referred to as “NBP Data”).

A. Definitions of NBP Data Elements covered by these terms:
1. Brain data (fMRI, EEG, NIRS)
2. Subject information (age, gender, handedness)

B. Qualification to Obtain Access:I, as an applicant, am expected to meet one of the following criteria to qualify as a party
granted access to NBP Data:
1. I am a Principal Investigator (PI) of scientific research at a university, a researchorganization (including commercial entities) or a government agency who is theleader of a laboratory or research team or who is working independently; or
2. I can provide the name of the PI who is overseeing my research and is approved
for access under #1.
3. If I do not meet either of the above criteria, I may still be considered qualified
based on a track record of scientific publications or on the basis of a writtenreference from someone who meets qualification #1, verifying that the data will
be used only for the purpose of legitimate scientific research.

C. Responsibility for NBP Data
1. ATR is responsible for the data uploaded to the NBP Database. If ATR finds any
bug or mistake, ATR will appropriately update the database and releaseinformationdescribingsuchchanges

ontheNBP

Databasewebsite(http://www.cns.atr.jp/dbi/download/).
2. ATR accepts no responsibility for any direct or indirect damage or any loss
attributed to the use of NBP Data.

D. Obligations of Applicant
I request access to NPB Data collected by the ATR Network-BMI Project (ATR-NBP). To
ensure proper use of NBP Data and to protect the privacy of NBP subjects, I agree toabide by the following terms.
1.
Initial☐ I am a Principle Investigator (PI) as defined above in B.1.
OR☐ I am not a PI.
Please complete and submit this application. ATR must
additionally receive an application from the applicant’s PI
before ATR can process this application.
☐ Name of PI (please print legibly)

2.

I will not redistribute the NBP Data.

3.

I will keep NBP Data secure (password protected so that the data are

Initial

Initialaccessible only to individuals who have already been granted access).
4.

InitialTo meet restrictions on publishing NBP Data elements of individual
subjects, I will assign and only use my own study-specific subject ID
for each individual, e.g. subjects A, B, C, etc.

5.
InitialI will use the NBP Data exclusively for the purposes of scientificresearch, technology development, and education under the auspicesof an academic, research, government or commercial entity.

6.
Initialpresentations, or other publicly available documents.
7.

InitialI will not assume or assert that ATR has any responsibility for any
direct or indirect damage or loss attributed to use of NBP Data.

8.
InitialI will contact ATR by email when I publish manuscripts, conference

I will cite NBP Data using the expressions given on the NBP Databasewebsite (http://www.cns.atr.jp/dbi/download/).

Applicant information (required for all applicants):

Name:
Position or title:(e.g. Professor, Postdoc, Graduate Student)
Institutional affiliation:
Highest academic degree:
Email address:
Daytime telephone number:

Applicant Signature

Date

 NOTE: Either electronic or handwritten initials and signatures will be accepted.
Submitting this application
The applicant should save this completed, signed and initialed form, naming it withapplicant’s family name and first initial (e.g. Yamada_T.pdf), and send it as a scanned
PDF file or JPEG/PNG/TIFF image to dbi_db@atr.jp.
 Please note that it may take up to a week before this application is considered forprocessing.
Questions about this document and its provisions should be sent to dbi_db@atr.jp.