Send Application to:

Vital Statistics Services

Wyoming Department of Health

Hathaway Building 1st Floor

2300 Capitol Ave.

Cheyenne, WY 82002

  1. ORGANIZATION OR INDIVIDUAL REQUESTING ACCESS
  1. Agency:
  2. Division/Program:
  3. Project Director Name and Title:
  4. Street Address or P.O. Box:
  5. City, State, Zip Code:
  6. Telephone: () - Email Address:
  7. Other persons who should be contacted if more information is needed:

Name:

Telephone: () - Email Address:

Address (if different than above):

  1. PROJECT
  1. Project Title:
  2. Is identifying information requested? YesNo

See list of items considered identifying or potentially identifying in Attachment A.

  1. Specify program name and any Mandate, Law, or Grant establishing purpose. For example, Cancer Registry, Public Health Law Section XXXX(x).

Program Name:

Mandate, Law, or Grant:

  1. Describe in detail how the program is directly related to part C:
  1. Is this information available from other sources? (If yes, describe why the other source(s) is not being used. If no, describe measures taken to evaluate other sources.)

Yes

No

  1. OTHER ORGANIZATIONS PARTICIPATING IN THIS STUDY OR PROJECT

List the name(s) of any organization which will obtain individually identifiable information from the Wyoming Department of Health, Vital Statistics Services (VSS) files. Include consultants, contractors, and data processing vendors. If you will be contracting out, please provide contact information and describe the nature of the work to be performed by contractor (name of official, name of organization, address of organization,phone numbers, work to be performed).

Are there sponsors for this project? If yes, give the name and address for each sponsor.

NameAddress

  1. SUMMARY OF STUDY PROTOCOL OR PROJECT ACTIVITIES

In responding, please be as clear as possible using the space provided. If you require additional space for answers, insert a separate page(s) and number each answer.

  1. Please state the purpose of your request for access to Vital Statistics Data.
  1. Briefly explain how the Vital Statistics Data will be used.
  1. Please describe any follow back procedures including who will be contacted (i.e., family, next of kin, etc.); how they will be contacted; information to be obtained from those contacted; methods to be used in obtaining information from those contacted; other organizations or consultants, if any involved in the individual contacts.
  1. RECORDS AND IDENTIFIABLE DATA REQUIRED
  1. Specify type of file(s), i.e., live birth, death, and year(s) or time period(s) for which access is requested:

Type of FileYear Type of FileYear

1) 2)

3) 4)

5) 6)

7) 8)

9) 10)

11) 12)

B. Please list the indirect identifier data items needed for data request:

  1. Please list any direct identifier data items needed for data request and provide a justification for each item:

Add pages to end if additional room is needed.

D. What type of request is this?

Routine

Non-routine

E. How many future requests do you expect to make?

F. Indicate the format in which you would like to receive the data?

Paper Email

CD SAS

Excel Flat File

Other, Explain

  1. Does this project include linking to another data source? (If yes, describe the other data source and the criteria which will be used to match the data).

H. In what form and who will receive the results of the study to activities?

VI. MAINTAINING THE CONFIDENTIALITY AND SECURITY OF IDENTIFIABLE INFORMATION

  1. How will you maintain the confidentiality and security of identifiable data obtained from VSS records? (Identifiable data refers to any information which could permit the identification of any individual. This is not only name and address, but also individual case record data where other demographic items such as age, sex, race, and place of residence could possibly be used to identify subjects).
  1. Disposition of Identifiable Data
  1. How long will you store copies or other identifiable data?
  1. How will you dispose of copies of records or other identifiable data?
  1. Will the identifiable data obtained from the records or follow back investigations be used either directly or indirectly for any project or purpose other than the one described in Part IV?

Yes

No

If yes, briefly describe other projects or purposes for which the data will be used. A separate application form must be submitted for each project which will be using protected data obtained from the VSS.

  1. Has this project previously been approved or disapproved by an Institutional Review Board (IRB)? (If approved or disapproved, please attach a copy of the approval or disapproval.)

Approved

Disapproved

IRB review and approval is not needed because activity is considered public health practice and not research (for example: epidemiological investigations, surveillance, and evaluations.)

  1. Will any of the identifiable data obtained from records and/or follow back investigations be used as a basis for legal, administrative, or other actions which may directly affect particular individuals as a result of their specific identification in this project?

Yes

No

  1. APPLICANT ASSURANCES

The undersigned hereby agrees to the following terms and conditions related to this application and to the use of information obtained from the Wyoming Department of Health (WDH):

  • To provide WDH with a written assurance in the form of a Data Use Agreement or similar agreement, that you will not further disclose the limited data set or its individually identifiable results, except as required by law or with express written permission from the WDH.
  • To prohibit further disclosure of the data without written consent from VSS.
  • To not attempt to contact the subjects of the data.
  • To use the information obtained from the Wyoming Vital Statistics Services for the specified project only. Other projects, regardless of how similar, will require a new application.
  • To submit a new data application if the scope of the project changes.
  • To submit an amended data application if the principal investigator changes.
  • To provide the Wyoming Vital Statistics Services a final copy of any publications, results, reports, etc., derived from the use of the data.
  • That the authorization to release this information does not imply endorsement of this study or its findings by Wyoming Vital Statistics Services or WDH. The following statement must be included in such publication or any other release of the data:

These data were supplied by the Vital Statistics Services, Wyoming Department of Health, Cheyenne, Wyoming. The Wyoming Vital Statistics Services was not involved in any analyses, interpretations, or conclusions.

All statements entered in this application are true, complete, and correct to the best of my knowledge and belief.

Project Director’s Name:

Project Director’s Title:

Organization:

______

SignatureDate

Attachment A

Identifying Data Elements from Wyoming Vital Records

Birth:Death:

Child’s First Name*Decedent’s First Name*

Child’s Middle Name*Decedent’s Middle Name*

Child’s Last Name*Decedent’s Last Name*

Child’s Birth DateDate of Death

Birth FacilityDecedent’s Social Security Number*

Birth CountyDecedent’s Date of Birth

Birth CityFacility’s Name

Mother’s First Name*Decedent’s City of Death

Mother’s Middle Name*Decedent’s County of Death

Mother’s Last Name*Decedent’s Resident County

Mother’s Maiden Name*Decedent’s Resident City

Mother’s Birth DateDecedent’s Resident Street Address*

Mother’s Resident CountyDecedent’s Resident Zip Code

Mother’s Resident CityDecedent’s Father’s First Name*

Mother’s Resident Zip CodeDecedent’s Father’s Middle Name*

Mother’s Resident Street Address*Decedent’s Father’s Last Name*

Mother’s Mailing CityDecedent’s Mother’s First Name*

Mother’s Mailing Zip CodeDecedent’s Mother’s Middle Name*

Mother’s Mailing Street Address*Decedent’s Mother’s Maiden Name*

Father’s First Name*Informant’s Name*

Father’s Middle Name*Informant’s Mailing Address*

Father’s Last Name*Injury Date

Father’s Birth DateOut of State File Number*

Father’s Social Security Number*Record Filed Date

Local Registrar Number*Certificate Number*

Mother Medical Record Number*

Infant Medical Record Number*

Certificate Number**Direct Identifier

Attachment A

Identifying Data Elements from Wyoming Vital Records

Marriage:Divorce:

Groom’s First Name*Husband’s First Name*

Groom’s Middle Name*Husband’s Middle Name*

Groom’s Last Name*Husband’s Last Name*

Groom’s Date of BirthHusband’s Resident City

Groom’s Legal Father’s Full Name*Husband’s Resident County

Groom’s Legal Mother’s Full Maiden Name*Wife’s First Name*

Bride’s First Name*Wife’s Middle Name*

Bride’s Middle Name*Wife’s Last Name*

Bride’s Last Name*Wife’s Maiden Name*

Bride’s Maiden Name*Wife’s Resident City

Bride’s Date of BirthWife’s Resident County

Bride’s Legal Father’s Full Name*Wife’s Date of Birth

Bride’s Legal Mother’s Full Maiden Name*Husband’s Date of Birth

Sworn DateCity Where Marriage Occurred

Issuing CountyCounty Where Marriage Occurred

Marriage DateDate of Marriage

City of MarriageDate Couple Last Resided Together

Occurrence CountyName of Petitioner’s Attorney

Officiant’s Name*Decree Certification Date

Officiant’s Street Address*Date Recorded

Officiant’s Telephone Number*County of Decree

Witness Names*Date of Death, Divorce, Annulment

Residence City

Local Official Name*

Local Official Resident City

Local Official Date Returned to WDH

County of Local Official

Date of Groom’s Previous Marriage

Date of Death, Divorce, Annulment

Groom’s Social Security Number*

Date of Bride’s Previous Marriage

Date of Death, Divorce, Annulment

Bride’s Social Security Number**Direct Identifier

Attachment A

Wyoming Department of Health, Vital Statistics Services

External Request

Page 1 of 9

June 1, 2011