Data Sharing Agreement Information Sheet

A Data Sharing Agreement (DSA) with the WA State Department of Health is required to receive Comprehensive Hospital Abstract Reporting System (CHARS), Birth, Fetal Death, Linked Birth-CHARS, and Linked Birth-Infant Death data files. To start the data sharing process, fill out this information sheet, then email to [email protected].

NOTE: Information on this sheet will be directly copied into the Data Sharing Agreement.

For descriptions of the available data sets, see: http://www.doh.wa.gov/DataandStatisticalReports/VitalStatisticsData/OrderDataFiles.aspx Data user’s name and email address:

Check the data set(s) you are requesting: ☐ CHARS ☐ Birth ☐ Fetal Death ☐ Linked Birth-CHARS ☐ Linked Birth-Infant Death

How long will you need the data/ length of project?

This agreement is to receive limited unidentified data. If your purpose is to re-identify or contact individuals or link to other data you will need approval from the Washington State Institutional Review Board.

Describe in detail how the data will be used and any provisions for re-disclosure.

Organization Name Business Contact Name Title Address Telephone # Email Address

Data User Contact Name Title Address Telephone # Email Address

IT Security Contact Name Title Address Telephone # Email Address

Privacy Contact Name Title Address Telephone #

DOH 422-113 August 2017

Email Address

Data User Contact: the person who will receive the data

Business Contact: a person with authority to sign the agreement for entire agency or organization. The Business Contact will be responsible for maintaining a signed Appendix A for all individuals who have access to the data file(s). Appendix A forms are available upon request.

IT Security Contact: a person with responsibility for ensuring data are stored and transferred in accordance with federal and state laws and regulations.

Privacy Contact: a person with responsibility for privacy/public disclosure requests; ensuring compliance with HIPAA; ensuring data are maintained in accordance with federal law.

DOH 422-113 August 2017