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Request for Access to Alberta Perinatal Health Program Database

Please use the "tab" key to move from field to field when completing this request form. Using the "enter" key will cause the form to automatically be submitted.

Name of the Individual Making the Request:

Title of the Individual Making the Request:

Telephone Number:

Email Address:

Specific Variables Required:

Time Frame - Year(s) of Data Required:

Purpose of Inquiry:

Intended Use of the Information:

Health Research Ethics Approval Provided:

Yes     Pending

Research Proposal Provided:

Yes     Pending

Will the project for which the data are required be funded?

Yes     No     Application Pending

Date when the Data are Required:

I hereby agree to the following conditions:

1. To comply with the Health Information Act and regulations made under the Act including but not limited to Sections 48  to 56.
2. Client confidentiality and identity will be protected.  Information that has the potential to identify an individual, hospital or physician can never be reported or published.
3. Data provided through this request will be used only for the research study for which it was approved.A second data request / approval is required if secondary analysis is proposed.
4. Data provided will be used by the undersigned applicant only unless otherwise stated in the request.
5. The data must be used appropriately, have restricted access, be maintained securely. Data will not be shared outside of the study team. Data must be stored on a computer that is protected behind a firewall and must not be stored on portable computers or external drives.
6. Data must be destroyed at the end of the study unless the researcher has been granted permission by the APHP to keep a copy of the data to meet the requirements for publication. The APHP must be notified when the project has been completed and the data has been destroyed.
7. The Alberta Perinatal Health Program will be granted the opportunity to examine any proposed manuscript and has the authority to remove parts considered improper or inappropriate for publication or transmission.
8. Presentations, reports, or publications using data from the Alberta Perinatal Health Program database(s) will acknowledge the program as the source of data. The extent of recognition (co-authorship etc) will be defined at the time the request is granted.
9. If the terms and conditions of this agreement are not met or are contravened, the agreement is cancelled.
10. The researcher(s) must not contact the research subjects to obtain additional information.
11. The APHP has the right to access the researcher's premises to confirm compliance with conditions of this agreement and the Health Information Act

If you agree to the above conditions, please place a checkmark here, in lieu of a signature.

Date: