IF THERE ARE ANY PROBLEMS, PLEASE CONTACT FAY O’SULLIVAN (Mon-Thurs):
Fay.O’
0191 2824186
PLEASE PROVIDE CONTACT DETAILS OF PERSON(S) FILLING OUT FORM OR WHO TO CONTACT IN THE EVENT OF QUERIES WITH APPLICATION IN “SUPPORTING INFORMATION” SECTION.
Project title*
Description of proposal*
Description of information / data to be transferred*
Does the information to be transferred include (please tick):
Clinical Subject Management* / Clinical Research* / Clinical Audit*Social Research* / Administration* / Teaching*
Sensitive data:
Ethnic Origin* / Physical Health* / Mental Health*Other*
Indicate whether Primary or Secondary Use (please refer to the User Guide):*
Primary*Secondary*
Indicate which data items have been requested:
Forename*Age*
Postcode*
Trust Study ID* / Surname*
Sex*
Partial Postcode*
Study/Database ID* / DoB*
Address*
NHS No.*
Email Address*
Diagnosis Code or Description* / Procedure Code or Details*
Please justify the need for each data item that you are collecting
Name of organisation receiving data*
Name of person responsible for release of data*
Name of person responsible for receipt of data*
Email address of person receiving information / data*
For what period is the data transfer required:
Start date*
End date*
Please state regularity of data transfer e.g. monthly*
Contact details of person responsible for receipt of data in relation to this form:
Name*
Address 1*
Address 2*
Address 3*
Town*
Region*
Country*
Postcode*
Telephone*
Email*
Method of information / data transfer (please tick):
NHSmail.net*Trust email* / Secure fax*
Special delivery / courier* / Removable media encryption AES 256*
Electronic File Transfer*
(Note - Patient/user identifiable data must only be transferred by e-mail using the secure NHS network i.e. @nhs.net or unless appropriate controls are in place i.e. encryption)
Who else will have access to the data?*
(If data recipients are not employed by the NHS please state whether NHS honorary contracts are in place. If not - detail confidentiality agreements.)
Location of recipient:
NHS Organisation* / Government Dept.* / UK*EEA Country* / Non EEA Country*
How will the service users be contacted?*
How will the service users consent be obtained?*
If no consent being obtained, please detail the reason why not e.g. exemption under Section 251 of the NHS Act 2006*
Where will the data be stored*
How will data be protected? (Please detail security measures to be taken)*
If the data is on a computer is there access via a network?*
Yes*No or N/A*
How long will the data be stored?*
At the end of this period how will the data be disposed?*
Name of person responsible to ensure that the data is disposed of in a confidential manner?*
Other supporting information e.g. Ethics approval, correspondence etc.*