Health Data Request - Submission Form for the Pre-public Disclosure Review of Statistical and/or Research Materials

Date of Submission:

In signing an Information Sharing Plan under the General Health Information Sharing Agreement, an Information Sharing Agreement or a Research Agreement with the Ministry of Health for access to data, applicants commit to sending Evaluation and/or Research Materials to the Ministry of Health in advance of public dissemination. Ministry of Health, as those responsible for ensuring appropriate uses of the public body’s data, check that: privacy / confidentiality requirements are upheld; there is no gross misuse of the data; and that the data is appropriately referenced. This also provides an opportunity for Ministry of Health to learn of, and brief internally on, the research findings.

PLEASE READ BEFORE SUBMITTING

  1. Your Agreement requires that you provide Ministry of Health 45 DAYS to review your submission.
  2. Submissions that have been previously vetted in a different publication format and do not use new data and/or analysis DO NOT require further vetting (Ministry of Health still request that copies be provided).
  3. Presentation of statistical and research materials to colleagues DO NOT require approval.

Please complete the form below for each item of Publication Material which is being submitted for review.

GENERAL DETAILS

Project Number:

Project Title:

Principal Investigator/Applicant:

Address/ Phone/ Email:

Organization:

TYPE OF MATERIAL FOR PUBLIC DISCLOSURE

Please select type:

Conference abstract

Presentation of research materials (posters, seminars, lectures, etc.)

Article for general public release (newspaper/magazine/blog/wiki etc.)

Op-ed for general public release (newspaper/magazine/blog/wiki etc.)

Journal publication

Academic thesis or dissertation material

Interview (radio, television, internet, etc.)

Instructional use (examples in lectures and/or lab exercises, etc.)

Other, please describe

Please list all databases relevant to this publication (e.g., MSP, DAD) *

AUTHOR DETAILS

Names of authors:

Names of authors who have access to the data released under this project:

PUBLICATION DETAILS

Title of publication:

Please describe how this publication ties to/supports the objectives of this project:

Additional information (If you would like to include additional information (such as details of the journal to which you are submitting or the event at which you are making your Material public) please do so here):

CONFIRMATIONS

Has this Material already been delivered/published?

Yes

No

I confirm that the attached document is the final draft to be submitted for publication

Yes

I agree to notify Data Stewards of any pre-publication changes made to this document and to provide a copy of the final document

Yes

I confirm that this publication does not contain any risk of re-identification of an individual

Yes

(e.g., small cell sizes, small geographic areas)

I confirm that all relevant databases are properly referenced (e.g., MSP, DAD)

Yes

Pre-Public Disclosure Review Submission Form March 2015