Name of project or initiative* must provide value
Project Number (if you have one assigned by Research & Capacity Building) Principal Investigator/Initiative Lead Name* must provide value
The Principal Investigator is the leader of the initiative, and the person who assumes responsibility for the appropriate protection, use and destruction of any data used for the initiative.
Principal Investigator/Initiative Lead e-mail address* must provide value
Principal Investigator/Initiative Lead phone number* must provide value
Principal Investigator/Initiative Lead position and institution* must provide value
Name of Primary Contact person for this data request (if different from the Principal Investigator/Initiative Lead) Primary Contact person e-mail address (if different from the Principal Investigator/Initiative Lead) Primary Contact Person phone number (if different from Principal Investigator/Initiative Lead) Please list the names, positions and institutions of all members of the project team who will have access to the requested data.* must provide value
Name(s) of Island Health data specialist(s) who assisted with this data request?* must provide value
Note: You can save this Request Form and return to it later. Click on "Save & Return Later" at the end of the form and be sure to record or e-mail yourself the link and access code that enable you to return to the form. Please provide a description of your project/initiative and the question you are trying to answer.* must provide value
If you have a project protocol, project charter, or other document describing your initiative/project, please attach it here. ( MB)
What kind of activity is the project/initiative involved in? (please indicate all that apply)* must provide value
Research
Quality Improvement
Quality Assurance
Evaluation
Contract with Island Health
Island Health-based Initiative
External Initiative
Other
Please explain what "other" kind of activity is involved.
If this project is supported by senior Island Health personnel (Director or higher), please provide their Name(s) and Position(s) at Island Health.
This Data Request form distinguishes three kinds of data. Please indicate the kind(s) of data the project will use. (Please indicate all that apply.) "Field data" (data generated by the project through participant enrollment, measurements, surveys, focus groups, interviews, etc.)
Island Health data (data from Island Health's data holdings)
External data (data from other sources e.g. PharmaNet, PopDataBC, provincial disease registry, etc.)
Study Population - Please use this Reference Document for the following question. Describe the study population
Which data will be used to identify/choose the study population? Indicate all that apply. "Field data" (individuals will be recruited as part of the research project)
Island Health data (Island Health's data holdings)
External data (data from other sources e.g. PharmaNet, PopDataBC, provincial disease registry, etc.)
Other
Please explain what "other" data will be used to identify the study population.
Estimated number of people in the study population
In most cases, data elements that can be linked to an individual are not provided for analyses or projects. If data elements that can be linked to an individual are required, the request will be reviewed by a Privacy Officer. Which of the following information that can be linked to an individual do you require? (check all that apply) Name
Medical Record Number (MRN)
Health Plan Number (PHN)
Encounter Number
Street address
Phone numbers
Fax Numbers
E-mail Addresses
Social Insurance Number (SIN)
Account Numbers
Vehicle identifiers and serial numbers, including license plate numbers.
Web Universal Resource Locators (URLs)
Certificate/License Numbers
Device identifiers and serial numbers
Internet Protocol (IP) address
Biometric identifiers, including finger and voice prints
Full face photographic images and any comparable images
Any other unique identifying number, characteristic, or code. (Note: this does not mean an encrypted study id or the unique code assigned by the investigator to code the data)
Other
Note: In accordance with privacy legislation, only the minimal amount of 'personal information' necessary for the project can be disclosed by Island Health.
Please explain "other" information required
Please explain why information that identifies individuals is essential to your initiative
Will participant consent be obtained? Yes
No
Please explain why consent will not be obtained
What data do you require that could conceivably increase the risk of identifying an individual? Dates (except year alone) directly related to an individual, including birth date, admission date, discharge date, date of death.
Information that will be stratified in a way that may result in groupings containing few individuals i.e. small cell size.
Individuals with a rare characteristic
Ages over 89 and all elements of dates (including year) indicative of such age, except as such ages and elements will be aggregated into a single category of age 90 or older.
Geographical subdivisions smaller than the initial three digits of a postal code.
Record-level information of a small, specifically defined population.
Other
Note: Data requests that do not include data that can be linked to an individual (listed previously), but that do include data that could increase the risk of an individual being identified, will be reviewed by a Privacy Officer. If the data extract carries significant risk for identification, some data elements may be aggregated or altered to reduce the risk.
Please describe
Please explain "other" data required.
Please explain why information that could conceivable identify an individual is essential to your initiative.
Please describe measures that will be taken to protect confidentiality (prevent the identification of an individual), during:a) analysisb) transfer of datac) storage of datad) destruction of datae) distribution of resultsf) publication
Please describe when the information that could identify individuals will be destroyed, and by whom.
Are ISLAND HEALTH data part of this project? Yes
No
Please identify the subject areas of the data required for your project. Choose all that apply. Admission Discharge Transfer (ADT)
BC Perinatal Database Registry (BCPDR)
BC Trauma Registry
Care Provider Order Entry (CPOE)
Community Health Services
Discharge Abstract Database (DAD)
Emergency Encounters
Employee Education
Employees & Positions
Employee Scheduling
Employment Applications
General Ledger
Hand Hygiene
Home Support
Infection Prevention & Control
Laboratory
Medical Imaging
Medication/Antimicrobial Stewardship
Mental Health & Substance Use
National Ambulatory Care Reporting System (NACRS)
Overtime
Payroll
Pediatric Intensive Care Database
Pharmacy
Residential Services
Staff Injury (OH&S)
Staffing Actions (Hire, Fire, Transfer)
Staff with Admitting Privileges (PRD)
Statistics
Surgery
Surgical Patient Registry
Transfusion Medicine
Other
Please explain other:
Please attach an Excel spreadsheet of a list and plain-language description of ALL ISLAND HEALTH DATA fields to be used for analysis (i.e. do not include fields used only for linkage that will not be retained for analysis). The Information Steward(s) adjudicate based upon the entire body of data used for analysis, and not only on the data under their authority or the use of specific identifiers. Please use the link on the right to upload the file ( MB)
Describe the data retrieval interval One time
Weekly updates
Monthly updates
Annual updates
Need to accrue to a maximum number of patients/cases
Other
If data are needed until a certain number of cases accrue, how many cases are required?
Please enter integer
Please explain "other" data retrieval interval:
When are the ISLAND HEALTH data required by? Today D-M-Y Note: data cannot be provided until after Institutional Certificate of Approval is issued by Research & Capacity Building.
Once the ISLAND HEALTH data are received, how long will they be needed for?
Will any of the data requested here, be needed/used for future projects related to this one? Yes
No
Please explain how it will be needed for future projects
Output format - indicate the preferred data file format. Access
Excel
tab/comma-separated value
fixed width file
Other
Please specify "other" format.
List the Information Steward(s) for the ISLAND HEALTH data related to this request. (Assistance to answer this question is available by contacting datarequest@viha.ca .) Additional fields will be provided for multiple information stewards. Subject area (a): Information Steward (a): Subject area (b): Information Steward (b): Subject area (c): Information Steward (c): Subject area (d): Information Steward (d): Subject area (e): Information Steward (e): Subject area (f): Information Steward (f): Subject area (g): Information Steward (g): Are "FIELD" DATA part of this project? Yes
No
Please describe the "FIELD" DATA that will be collected as part of the initiative/project:
Please attach an Excel spreadsheet of a list and plain-language description of ALL "FIELD" DATA fields to be used for analysis (i.e. do not include fields used only for linkage that will not be retained for analysis). The Information Steward(s) adjudicate based upon the entire body of data used for analysis, and not only on the data under their authority or the use of specific identifiers. Please use the link on the right to upload the file ( MB)
Will electronic or paper "FIELD" DATA be stored or managed at Island Health Yes
No
Please specify Database
Island Health computer
File share
REDCap
SharePoint site
Paper file
Other
Please describe how "FIELD" DATA will be stored
Please identify the "FIELD" DATA files as follows: Enter Information for Filename "a" "FIELD" DATA Filename (a)
Data collection type Survey
Interview
Other
If "other", please describe how the data will be collected.
From Date Today Y-M-D To Date Today Y-M-D Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Collected data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "b" "FIELD" DATA Filename (b)
Data collection type Survey
Interview
Other
Please describe how the data were collected.
From Date Today Y-M-D To Date Today Y-M-D Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Collected data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "c" "FIELD" DATA Filename (c)
Data collection type Survey
Interview
Other
Please describe how the data were collected.
From Date Today Y-M-D To Date Today Y-M-D Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Collected data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "d" "FIELD" DATA Filename (d)
Data collection type Survey
Interview
Other
Please describe how the data were collected.
From Date Today Y-M-D To Date Today Y-M-D Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Collected data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "e" "FIELD" DATA Filename (e)
Data collection type Survey
Interview
Other
Please describe how the data were collected.
From Date Today Y-M-D To Date Today Y-M-D Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Collected data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Are EXTERNAL DATA part of this project? Yes
No
Please describe the EXTERNAL DATA that are required for this research project:
Note: It is the Applicant's responsibility to apply for use of external data. Copies of applications and final approvals to use and link data from an external source must be submitted as part of the application package.
Please attach an Excel spreadsheet of a list and plain-language description of ALL EXTERNAL DATA fields to be used for analysis (i.e. do not include fields used only for linkage that will not be retained for analysis). The Information Steward(s) adjudicate based upon the entire body of data used for analysis, and not only on the data under their authority or the use of specific identifiers. Please use the link on the right to upload the file. ( MB)
Please identify the EXTERNAL DATA files as follows: Enter Information for Filename "a" Source of EXTERNAL File "a"
EXTERNAL DATA File (a) From Date Today D-M-Y To Date Today D-M-Y Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Field data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "b" Source of EXTERNAL File "b"
EXTERNAL DATA File (b)
From Date Today D-M-Y To Date Today D-M-Y Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Field data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "c" Source of EXTERNAL File "c"
EXTERNAL DATA File (c) From Date Today D-M-Y To Date Today D-M-Y Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Field data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "d" Source of EXTERNAL File "d"
EXTERNAL DATA File (d)
From Date Today D-M-Y To Date Today D-M-Y Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Field data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
Enter Information for Filename "e" Source of EXTERNAL File "e"
EXTERNAL DATA File (e)
From Date Today D-M-Y To Date Today D-M-Y Will this file be used for linkage? Yes
No
Name of fields to be used for linkage
Please separate with commas
Retain the linkage field for analysis? (Yes or No) Yes
No
What will this file be linked to? Island Health data
Field data
External data
Please explain the purpose of this linkage.
Where will the linkage be performed?
Note: Unless otherwise stated, it is expected that linkage will occur at Island Health.
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