Data Request for Research Form

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

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Postal Code

Invalid Input

Part B: Description of Research Project

Project Title(*)

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Description and objectives of the project:

0/750

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Is the research funded?(*)

Yes No Invalid Input

Name of funding agency

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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

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

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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

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.

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Received

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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

Invalid Input

Comments

Invalid Input

Data Management Group notified:

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DM Data Request Form submitted

Invalid Input

Data Request Form

Instructions for use:

Part A: General Information

Part B: Description of Research Project

Please review the Cost Recovery Fee Structure

Part C: Description of Data

Name(s) of study staff* that will be using data (including email):

Part D: Security

TOH Patient Privacy Policy #000175

RPPEO USE ONLY

In this section