<p>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]. </p><p>NOTE: Information on this sheet will be directly copied into the Data Sharing Agreement. </p><p>For descriptions of the available data sets, see: http://www.doh.wa.gov/DataandStatisticalReports/VitalStatisticsData/OrderDataFiles.aspx Data user’s name and email address:</p><p>Check the data set(s) you are requesting: ☐ CHARS ☐ Birth ☐ Fetal Death ☐ Linked Birth-CHARS ☐ Linked Birth-Infant Death</p><p>How long will you need the data/ length of project?</p><p>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.</p><p>Describe in detail how the data will be used and any provisions for re-disclosure. </p><p>Organization Name Business Contact Name Title Address Telephone # Email Address</p><p>Data User Contact Name Title Address Telephone # Email Address</p><p>IT Security Contact Name Title Address Telephone # Email Address</p><p>Privacy Contact Name Title Address Telephone #</p><p>DOH 422-113 August 2017</p><p>Email Address</p><p>Data User Contact: the person who will receive the data</p><p>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.</p><p>IT Security Contact: a person with responsibility for ensuring data are stored and transferred in accordance with federal and state laws and regulations.</p><p>Privacy Contact: a person with responsibility for privacy/public disclosure requests; ensuring compliance with HIPAA; ensuring data are maintained in accordance with federal law.</p><p>DOH 422-113 August 2017</p>