CSR-F-28 V3

Details of individual requesting data
Name
Position
Organisation
Address
Work phone number / ()
Mobile phone number / ()
Fax number / ()
Email address
Please provide the details of any co-investigators who willalso have access to the data.
Name / Position / Organisation / Phone number / Email address
This document is to be read inconjunction with the information brochure titled:
Information for individuals or organisations requesting data from the VCSR
Please ask for a copy of this document if you do not have it.
Section A- Complete for all data requests
1. What information do you require? (1-2 sentences).
2. What is the reason for the data request?
3. What are the research questions? How will the data be used?
4. Will there be any analysis of the data? (ie: data manipulation, calculation of rates etc).
Please note that data provided by the VCSR is to be used only for the explicit purpose stated above.
Yes / No
If Yes, please describe the planned method of analysis.
5. Is the study being submitted for external peer review or a funding application? If so, please attach a copy of the application.
Application attached?
N/A / Yes / No
6. Will the data be published? (including in manuscripts, abstracts, presented at conferences, used in education sessions or another format)
Yes / No
If Yes, where, in what format and in what time frame?
Please note that one of the conditions of data release is that third parties must not publish data without first informing the VCSR. Copies of all reports, manuscripts and presentations must also be provided to the VCSR.
7. What time period of data is required? Please specify a date range for the data requested.
Note that the cervical screening interval for screening tests (cytology tests) taken on or before 30 November 2017 was 2 years. From 1 December 2017, the cervical screening interval for screening tests (HPV tests) is 5 years.
8. What geographical area(s) are required? (eg:LGAs or postcodes).
9. What age groups are required (range and age bands)?
Note that the National Cervical Screening Program targeted screening age changed from women aged 20 to 69 years to women aged 25 to 74 years, on 1 December 2017.
10. In what format would you prefer the data? (eg: Excel, formatted tables, CSV).
11. Please insert below or attach mock-up tables of how you would like the data to be presented.
12. What security measures will be taken to safeguard the data?
13. For what length of time will the data be kept?
Please note that as per the conditions of release the data must be destroyed within 5 years and the VCSR must be informed when this has been done.
14. Do you require individual record data or line data? (ie: not summary data)
Yes / No
If Yes, please proceed to Section B
If No, please proceed to Section C to sign this request.
Go to Section B Go to Section C
Section B- complete for individual or itemised line data requests
Please discuss your requirement for line data with the VCSR.
HREC approval is required for the release of individual record or line data. Please attach a copy of your research proposal, HREC submission and HREC approval to this request form.
HREC approval can be provided by your local or host HREC, or apply to the Department of Health HREC.
Note: the VCSR is prohibited from providing identifying information on an individual without consent. Consent forms must be provided to the VCSR in order for data to be released.
1. Is a copy of your fullresearch proposal attached?
Yes / No
If No, please explain.
2. Is a copy of your HRECsubmission attached?
Yes / No
If No, please explain.
3. Is a copy of your HREC approval attached?
Yes / No
If No, please explain.
4. Are you seeking individually identified data for use in a clinical or epidemiological study in which the individual is participating?
Yes / No
If Yes, do you have individual consent to obtain the data from the VCSR?
Yes / No
If No, please explain how the public interest in the research outweighs the public interest in adhering to the relevant information privacy principle(s).
5. Are you seeking data for the purpose of formal data linkage to another data set or data sets (i.e. through a data linkage unit)?
Yes / No
If Yes, do you have in principle approval from the custodian of the other data set?
Yes / No
6. In addition to the mock-up table requested in the previous section, please provide a full list of requested data items required.
Please proceed to Section C below.
Section C- Conditions for the release of data
I understand that by accepting data from the VCSR I will:
(Please check the box)
  1. comply with relevant legislation (including the Australian Privacy Principles (under the Privacy Act 1988 Cth), Health Privacy Principles (established under the Health Records Act 2001 Vic), and NHMRC GuidelinesUnder Section 95/95A of the Privacy Act 1988);

  1. ensure that data from the VCSR will only be used for the purpose specified for this request;

  1. not publish VCSR data without first informing the VCSR;

  1. provide a copy of all released reports, published manuscripts and presentations to the VCSR;

  1. acknowledge VCSR in published material;

  1. comply with any other requirements specified by the VCSR as a condition of data release;

  1. ensure that any data, whether identified or de-identified, are stored securely and only those named on this application form will have access to it;

  1. ensure that published data will not be in a format that could potentially identify an individual;

  1. not link VCSR data to another data set without appropriate approval;

  1. notify the VCSR of changes of staff who hold the VCSR data;

  1. destroy VCSR data within 5 years of the date of receipt and notify the VCSR when this has been done;

  1. complete an annual update, or more frequently if requested, regarding the status of the research and use of the data,andconfirm ongoing safe storage of the data; and

  1. agreeto pay an administration fee if applicable.

(Please check the box)
I have read the accompanying information sheet titled “Information for individuals or organisations requesting data from the VCSR” and agree to the conditions of release and use of the data.
Are the additional required documents attached? Including:
(Please check the appropriate box)
  • Application for external peer review or a funding application(Section A, Q5)
/ N/A / No / Yes
  • An example of table format/ mock up tables
(Section A, Q11) / N/A / No / Yes
  • A copy of the research proposal for a line data request (Section B, Q1)
/ N/A / No / Yes
  • HREC submission for a line data request(Section B, Q2)
/ N/A / No / Yes
  • HREC approval for a line data request (Section B, Q3)
/ N/A / No / Yes
Signature (requestor):
Date:
This request form can be submitted by fax: (03) 9349 1818
or emailed to the Data Team:

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