Data Request Form Please complete all required fields! Instructions for use: To submit a request online please complete parts A, B, C and D and read the TOH Privacy Policy. A copy of the completed form will be sent to the email address you provide in Part A. Part A: General Information Principal Investigator Contact Information First Name(*) Please enter your first name. Last Name(*) Please enter your last name. Organization(*) Please tell us where you work Address Invalid Input Email(*) Please enter a valid email address Phone(*) Invalid Input Fax Invalid Input City Invalid Input Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanNorthwest TerritoriesNunavutYukon Invalid Input Postal Code Invalid Input Next > Part B: Description of Research Project Project Title(*) Invalid Input Description and objectives of the project: 0/750 Invalid Input Is the research funded?(*) Yes No Invalid Input Name of funding agency Invalid Input If no, will you be applying for funding? Yes No Invalid Input Will you be submitting your project for REB approval? (Note: A copy of the REB approval or the REB waiver will be required.)(*) Yes No Invalid Input If no, have you received, or will be submitting for, a waiver of REB review. Invalid Input Please review the Cost Recovery Fee Structure Cost Recovery Fee Structure I have read the Cost Recovery Fee Structure(*) Yes Invalid Input < PrevNext > Part C: Description of Data Please provide a detailed description of the data you are requesting (population, sample size, date range of data) including rationale and justifications. 0/500 Invalid Input Additional comments 0/500 Invalid Input Specify type of data requested: (Is it aggregate, de-identified, identifiable, etc...?) Invalid Input Please provide a description of the analysis to be performed on the data: 0/500 Invalid Input Name(s) of study staff* that will be using data (including email): * As per the Data Transfer Agreement Section 4(A), study staff permitted access to the data must have signed a confidentiality or non-disclosure agreement with your institution. Name Invalid Input Name Invalid Input Name Invalid Input Email Invalid Input Email Invalid Input Email Invalid Input Date when data required(*) ... Invalid Input Please provide any relevant time scheduling requirements. Invalid Input Would like to discuss with RPPEO Yes No Invalid Input < PrevNext > Part D: Security TOH Patient Privacy Policy #000175 This policy applies to all TOH Staff, all TOH hospital sites, and to all TOH Agents. TOH is committed to protecting the privacy of our patients and safeguarding the personal health information (PHI) with which we are entrusted. This policy establishes rules for the collection, use, and disclosure of PHI held at TOH in order to protect patient privacy and to ensure the delivery of safe and effective healthcare services. View TOH Policy 00175 After you have reviewed the TOH Policy check the box below to continue.(*) I have read The Ottawa Hospital Privacy Policy No. 00175 Please review the TOH Policy and check the box to continue. Please describe how the data will be protected (must be in accordance with safeguards described in the TOH Privacy Policy). Invalid Input RPPEO USE ONLY Request No. Invalid Input Received Invalid Input Request reviewed by RPPEO Invalid Input RPPEO/Paramedic(s) Author(s): Invalid Input Request reviewed by Service(s): Invalid Input Letter of support sent Invalid Input Data transfer agreement completed Invalid Input Request ApprovedDenied Invalid Input Comments Invalid Input Data Management Group notified: Invalid Input DM Data Request Form submitted Invalid Input
Please complete all required fields!
To submit a request online please complete parts A, B, C and D and read the TOH Privacy Policy.
A copy of the completed form will be sent to the email address you provide in Part A.
0/750
Cost Recovery Fee Structure
0/500
* As per the Data Transfer Agreement Section 4(A), study staff permitted access to the data must have signed a confidentiality or non-disclosure agreement with your institution.
This policy applies to all TOH Staff, all TOH hospital sites, and to all TOH Agents. TOH is committed to protecting the privacy of our patients and safeguarding the personal health information (PHI) with which we are entrusted. This policy establishes rules for the collection, use, and disclosure of PHI held at TOH in order to protect patient privacy and to ensure the delivery of safe and effective healthcare services.
View TOH Policy 00175
