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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
Please enter your first name.
Please enter your last name.
Please tell us where you work
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Please enter a valid email address
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Part B: Description of Research Project

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0/750

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Part C: Description of Data

0/500

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0/500

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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.

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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

Please review the TOH Policy and check the box to continue.
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RPPEO USE ONLY

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Medical Directives App

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