Please send a scanned copy of the complete, signed request form to

INTERNAL DATABASE CREATION REQUEST FORM
NAME OF REQUESTER:______
TITLE/POSITION:______
DEPARTMENT:______
DATE:______
DATABASE NAME:______
DATABASE TYPE:______
PART I: DATABASE CREATION
  1. Purpose Of Creation (check all that apply)

  1. Internal program or service delivery provided or funded by TOH [s.37(1)(c)]

  1. Internal program or service evaluation or monitoring [s.37(1)(c)]

  1. Internal fraud prevention [s.37(1)(c)]

  1. Risk management, error management or quality of care, program or service quality improvement [s.37(1)(d)]

  1. Education of TOH staff or those providing services on behalf of TOH [s.37(1)h)]

  1. Proceedings or contemplated proceedings in which TOH is expected to be a party or a witness [s.37(1)(h)]

  1. Obtaining payment or verifying claims for health services [s.37(1)(i)]

  1. Research [s.37(1)(j)] (Please contact the REB)

  1. Other

  1. Please provide a detailed explanation of the purpose (Please refer to the purposes generally set out in A. above.)
______
______
______
PART II: DATABASE CONTENT
  1. Data Elements: List all of the data elements that you wish to include in the database.
______
______
______
Explain why all of these data elements are required for the purpose of the creation of the database and why identifiable patient data is required.
______
______
______
  1. Data Source (s): List the source(s) for all of the data elements that you propose to include in the database. If the elements come from different sources, please indicate the source for each data element.
______
______
______
  1. Data Source Approval: Has approval been sought from the custodian of the source data to use it to create this database? Please explain.
______
______
______
PART III: DATABASE DISCLOSURE
  1. Will the database or any results from the analysis of the data be disclosed to anyone outside of TOH? Yes No

  1. If ‘yes’, please describe the form/format in which the information will be disclosed.
______
______
______
  1. If ‘yes’, please list the name of the individual(s), their affiliation(s) and the purpose for which the data will be disclosed:
NameAffiliationPurpose of the Disclosure
______
______
______
PART IV: GOVERNANCE OF THE DATABASE
  1. Who will be responsible for managing the database?
______
  1. Where will the database be housed? (i.e. the technological and physical location of the database)
______
  1. Who will have access to the database? (This question relates to access by TOH employees and their agents. Please name the individual, their position and why they require access; i.e. how it will be used internally).
NamePositionReason for Access
______
______
______
______
  1. Describe the physical and technological safeguards that will be applied to protect the database.

  1. How long will the database be retained in a form that includes identifiable patient information?

  1. Please explain what will be done with the database after the purpose for which is created has been satisfied.

Please send a scanned copy of the complete, signed request form to

InternalDatabaseRequestForm (version July 19, 2016)

Please send a scanned copy of the complete, signed request form to

PART VI: ADDITIONAL COMMENTS

Requestor Signature:______

Date:______

INFORMATION AND PRIVACY OFFICE (IPO) COMMENTS

______

______

______

IPO Signature:______

Title:______

Date:______

Please send a scanned copy of the complete, signed request form to

InternalDatabaseRequestForm (version July 19, 2016)