NHVPR-F-12_V7

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 in conjunction with the information brochure titled: Information for researchers requesting data from the NHVPR.
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? If the request is for a research project, please attach a project outline.
3. Will there be any secondary analysis of the data? (ie: data manipulation, calculation of rates etc).
Yes / No
If Yes, please describe the planned method of analysis.
Please note that data provided by the NHVPR is to be used only for the explicit purpose stated above.
4. Will the data be published? (details of 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 datawithout first informing the NHVPR. Copies of all reports, manuscripts and presentations must alsobe provided to the NHVPR.
5. What geographical area(s) are required? (eg: State, LGA or postcode).
6. What age groups and gender are required (range and age bands)? Please specify age in the calendar year required (eg. 12-14 in 2014).
7. In what format would you prefer the data? (eg: Excel, formatted tables, CSV).
8. Please insert below or attach a mock-up table of how you would like the data to be presented.
9. What security measures will be taken to safeguard the data?
10. Where and 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 NHVPRmust be informed when this has been done.
11. 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 NHVPR.
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.
Note: the NHVPRis prohibited from providing identifying information on an individual without their consent. Consent forms must be provided to the NHVPR 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 HREC submission 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 NHVPR?
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 data linkage to another data set or data sets?
Yes / No
If Yes, do you have in principle approval from the custodian of the other data set?
Yes / No
Section C- Conditions for the releaseand use of data
I understand that by accepting data from the NHVPRI will:
(Please check the box)
  1. comply with relevant legislation including the Australian Privacy Principles (APPs) contained in schedule 1 of the Privacy Act 1988 (the Privacy Act), and any relevant health privacy principles in force in State based legislation under whose jurisdiction the data request falls;
  2. ensure that data from the NHVPR will only be used for the purpose specified for this request;

  1. not recalculate or publish NHVPR data without first informing the NHVPR;

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

  1. acknowledge NHVPR in published material;

  1. comply with any other requirements specified by the NHVPR or DOH 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 consumer (for example cells with less than 10 individuals);

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

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

  1. destroy NHVPR data within 5 years of the date of receipt and notify the NHVPR 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, and confirm ongoing safe storage of the data; and

  1. agreeto pay any cost recovery fee if applicable.

(Please check the box)
I have read the information sheet titled “Information Brochure for Researchers Requesting Data from the NHVPR” document and agree to the conditions of release and use of the data.
Signature (requestor):
Name and Position (requestor):
Date:
This request form can be submitted by fax : (03) 8417 6835
or emailed to the NHVPR Data Requests emailat

Page 1 of 4