BRFSS DATA USE FORM

Instructions:Please complete the form, obtain required signatures, and submit to the attention of the BRFSS and OHT Survey Coordinator to the above address, fax, or email to: .

CONTACT INFORMATION FOR DATA REQUEST

Contact Name:

Email:Telephone:

Organization:Is this a government agency?YesNo

Street Address:

City:State:Zip Code

Is this request to: YesNo

Add a user for data already received?

Receive annual data on a regular basis?

Linkrecords to other databases?

Receive data tables?

DATASET REQUESTED:

BRFSS

2016 BRFSS

2015 BRFSS

2014 BRFSS

2013 BRFSS

2012 BRFSS

2011 BRFSS

2010 BRFSS

2009 BRFSS

BRFSS

2008 BRFSS

2007 BRFSS

2006 BRFSS

2005 BRFSS

2004 BRFSS

2003 BRFSS

2002 BRFSS

2001 BRFSS

FORMAT:What statistical software will you use to analyze the data?

Requestor will be notified of any fees ($70 an hour; total based on request) that must be paid prior to processing the data request.

DESCRIPTION OF STUDY

Study Start Date:Study End Date:

Does your study have IRB approval? YesNoIf “yes”, please attach copy of current IRB approval.

Describe plans for secure data storage, including laptops and other portable devices.
Describe plans to destroy the data after the study ends. Please provide a description of the studydetailing how the data will be used. Attach additional pages if needed.

DATA USE CONFIDENTIALITY AGREEMENT

I certify that I have read and agree to abide by the Database Confidentiality Rules on the attached sheet (please sign and date below).

X

Principal Investigator/ManagerPrinted NameDate

X

User 1 with access to DataPrinted NameDate

X

User 2 with access to DataPrinted NameDate

X

User 3 with access to DataPrinted NameDate

If user publishes a peer-reviewed manuscript from these data, PHD would appreciate receiving a copy of the abstract prior to publication.

DATABASE CONFIDENTIALITY RULES

Researchers (including all those who will use or have access to the requested dataset) who are requesting Oregon Health Division, Program Design and Evaluation datasets must agree to abide by the rules listed below.

  1. Data may be used only for the purposes stated in the approved Data Use Agreement. Any changes in planned use of data must be written as a supplemental request and receive written approval from Program Design and Evaluation Services, as well as the Oregon Public Health Division Institutional Review Board (PH-IRB) where necessary.
  2. Because researchers will have access to potentially identifiable individual record information, researchers must agree to assess the impact on privacy and confidentiality before publishing aggregated results. Identifiable information includes, but is not limited to, demographic identifier information, which will identify or may reasonably lead to the identification of one or more specific individuals. Researchers will apply the same rules of confidentiality when reporting non-identified aggregates, where disclosure of detailed geographic information could make it possible to identify the person in local communities.
  3. Researcher agrees that only those who have signed this data use agreement can access the Oregon BRFSS data. The Principal Investigator/Manager is responsible for assuring that all users follow the restrictions and conditions specified in this confidentiality statement.
  4. Researcher will protect confidentiality by using appropriate safeguards to prevent use or disclosure of the SWS data by any person not specified in the Data Use Agreement (e.g. use a password protected screensaver when possible, store data on encrypted memory, and keeping laptops, records and materials in a secure location with controlled access so that persons not connected with the study cannot access these records). Control of these records is to continue at the completion of the study by destroying the electronic files or listings.
  5. Researcher will not attempt to link individual records from this dataset with other information from any other dataset without specific written permission or approval from the Oregon PH-IRB. Linkage of information from multiple databases is a potential threat to confidentiality.
  6. Researcher will make no effort to determine the identity of individuals from the Oregon BRFSS data released. Identity discovered inadvertently is a breach of confidentiality and should be reported to the Oregon BRFSS data team immediately. Researcher will notify the Oregon BRFSS data team at if the researcher becomes aware of any use or disclosure of the Oregon BRFSS data not specified in the Data Use Agreement.
  7. Prohibition against follow-up: The researcher will not perform any individual or family follow-up, and no data will be published or disclosed from which an individual can be identified except upon written authorization of the Oregon OHA-HS IRB.
  8. Researcher will not release any individual record information either in toto, or in fragmented form, to any person or entity outside of the research team specifically related to the project described in the Data Use Agreement, without express written permission from the Oregon Public Health Division, Program Design and Evaluation Services.
  9. Researcher understands that a breach of confidentiality would result in denial of all future dataset requests from the Oregon Public Health Division, Program Design and Evaluation Services, as well as possible civil and/or criminal liability of the researcher. The Oregon Public Health Division has taken reasonable precautions to protect the identities of individual respondents providing information for this dataset. Researchers will accept all liability for their use, disclosure, or revealing in any way of information that can be used to identify any individual person.
  10. Researcher will ensure that the dataset is destroyed after the purpose of the written request is fulfilled. Even after researchers no longer have access to the survey data, they should consider themselves bound by this document and must continue to maintain the confidentiality of information to which they previously had access.