Department of Health Information Tel: (+356) 25599000
95 Guardamangia Hill Fax: (+356) 25599385
Guardamangia MSD 08
MALTA

Request for Record Level Data

/

Request Number:______

Date Received: ______

General Information:

  • You are advised to contact DHI staff prior to completing this form to discuss your data requirements.
  • DHI has a privacy protection policy for the release of data, a copy of which is attached to this form
  • DHI requires requestors to obtain authorisation for the release of person-identifiable data and authorisations for the release of institution-identifiable data (where applicable).
  • In order to protect confidential information, DHI undertakes to review all requests for data. You will be informed of the outcome in due course.
  • Prior to release of data, DHI will require that you have read and signed thePolicy for Request for Record Level Data Files, which is attached to this form, and that you will subsequently fully abide by this policy.
  • We are committed to protecting our clients’ privacy, as per the Data Protection Act 2001, and we will not collect any personal information about you unless you provide it voluntarily. Any information submitted will be used to respond to your request and will be held for a maximum of 5 years for departmental audit purposes. Any individual may request to see any information held about him/her and correct any personal details, if applicable.

PART 1Principal Requestor/Principal Investigator

full name and title: ______

address:______

title /designation: ______

organisation/department:______

address (if different from above):______

______

position held: __staff member / student / other (please specify)______

telephone no: ______fax no: ______

e-mail address: ______

PART 2Data Requested

description of data needed:______

______

time period (for which data is required):______

list (or attach) data elements requested together with rationale for their need:

Data Elements / Rationale

TARGET DATE FOR RECEIPT OF DATA:______

preferred format:Paper E-MailFloppy Disk (please supply)

(Please circle response)

PART 3Details of Project/Research Study

short title: ______

funding:

Is this project funded?Yes_____No_____

If yes, by whom:______

purpose/objective of the project:______

______

description of data analysis:______

______

description of benefits to be derived from this research project:______

______

HAS ETHICAL APPROVAL BEEN OBTAINED FOR THE PROJECT? Yes______No______

If yes, please attach a copy of approval/clearance.

If no, please explain: ______

______

______

PART 4Identifiable Data and Privacy

please explain why you cannot use anonymised or aggregate data:______

______

SPECIFY IF RESEARCH PROJECT WILL INCLUDE CHILDREN OR PEOPLE UNABLE TO GIVE FULL INFORMED CONSENT______

If yes, please explain necessity on including these individuals in the project:_____

______

HAVE YOU OBTAINED CONSENT FROM RESEARCH SUBJECTS AND AUTHORISATIONS FROM INSTITUTIONS CONCERNED (WHERE APPLICABLE)? Yes_____ no_____

If yes, please attach a copy of your consent form and authorisation form

If no,

Either,Give details of how consent is planned to be obtained:______

______

______

Or, Explain why it is impracticable or not feasible to obtain consent and why? ______

Does an Act of Law require disclosure of the requested data without the need for consent? If yes, please specify the Act and relevant Article.

______

______

DOES YOUR ORGANISATION/DEPARTMENT HAVE A PRIVACY POLICY?

yes_____No_____

If yes, attach a copy

Does your project involve linking any data from this request to other data?

yes_____No_____

If yes,

Describe what data are to be linked:______

______

______

Describe the rationale for this linkage:______

______

______

how do you intend to disseminate and/or publish the results of your Analysis?

______

what is the expected date of dissemination and /or publication?______

______

describe how you will ensure that data will be aggregated prior to disclosure?

______

Please describe the administrative, technical and physical safeguards that will be used to protect the confidentiality and security of the requested data.

______

DATA ARE TO BE KEPT ONLY FOR THE TIME SPECIFIED HERE UNDER. DESCRIBE HOW THE DATA WILL BE DISPOSED OF. ______

PART 5Termination

In making this request, I acknowledge that failure of myself or other persons listed in Part 6 of this form, to comply with the terms and conditions of the POLICY FOR REQUEST FOR RECORD LEVEL DATA FILES,I/WE i) shall return the data provided by DHI ii) will be held responsible for the destruction of all copies made iii) will be liable to reporting to the Ethics Committee, Data Protection Commission and possibly legal proceedings against me/us.

______

Date Signature of Requestor

PART 6Individuals requiring access to the requested data

Please complete Part 6 for each person (e.g. co-investigator, research staff etc) who would have access to the requested identifiable data. Additions or substitutions at a later data require DHI’s prior written authorisation.

All members of the research team who may use personal medical information should be placed under a duty of confidentiality equivalent to that of a health professional.

Prior to the approval of this request and before DHI will release the requested information, the requestor and each individual listed in this Part must sign the Policy for Requests for Record level Data Files.

1. Name, Surname and Title:______

Position ______

Address: ______

______

______

Organisation: ______

Telephone Number: ______

2. Name, Surname and Title:______

Position ______

Address: ______

______

______

Organisation: ______

Telephone Number: ______

3. Name, Surname and Title:______

Position ______

Address: ______

______

______

Organisation: ______

Telephone Number: ______

4. Name, Surname and Title:______

Position ______

Address: ______

______

______

Organisation: ______

Telephone Number: ______

5. Name, Surname and Title:______

Position ______

Address: ______

______

______

Organisation: ______

Telephone Number: ______

6. Name, Surname and Title:______

Position ______

Address: ______

______

______

Organisation: ______

Telephone Number: ______

For official use only:

Permission from relevant authorities needed yes____ no____

Ethics approval needed yes____ no____

Date in:______Collected by: ______Date given:______

Date Out: ______Processed by:______

Type: CustomisedAgreed time frame:______

1

DHI – Request Form for Record Level Data

 Please attach a letter from your academic head which:

  • Supports the planned research and attests to your ability to complete it
  • Confirms that you are enrolled as a full time or part time student in a diploma/graduate degree course and that the research will be used for fulfilling diploma/degree requirements.

 Document at which stage of the research will data be anonymised (if applicable), and security measures to be taken to protect the data e.g. locked/controlled access, secure storage facilities of backup copies, personal password security, etc.