Application form for AN authorization to Receive personal information disclosure for research, study or statistical purposes
Application date Application according to Article 125 of the Act respecting access to documents held by public bodies and the Protection of personal information, R.S.Q. c. A-2.1 (public act)
Application according to Article 21 of the Act respecting the Protection of personal information in the private sector, R.S.Q. c P-39.1 (private act)
A / Identification of applicant in charge of protecting personal informationFamily Name / First name / Telephone
() – / Extension
Establishment / E-mail address
@
Address / City / Postal code
year-m-d
B / Identification of person to contact (if different from A)Family Name / First name / Telephone
() – / Extension
Establishment / E-mail address
@
Address / City / Postal code
Names of co-investigators:
Research title:
Granting agency(ies)Type of application
New research
Modification to an authorization granted by the Commission CAI File no. : Authorizaton date:
year-m-d
Extension of the holding period of the information authorized by the Commission CAI File no. : Authorization date::
year-m-d
Secondary use of information authorized by the Commission in the context of another research project CAI File no.:
Others Explain:
Research Ethics Committee
Have you received an evaluation from an ethics committee regarding this study before submitting this application?
Yes— Identify the committee and attach a copy of the acceptance letter Application in progress Expected approval date
year-m-d
No Justify:Identify the organization(s) holding the requested personal information
(You must contact the Information Custodian(s) prior to submitting your application to the Access to Information Commission)
Québec Health Insurance Board (RAMQ) / Ministry of Health and Social Services (MSSS) / Ministry of Employment and Social Solidarity (MESS)Québec Statistics Institute(ISQ) / Ministry of Agriculture, Fisheries and Food (MAPAQ) / Ministry of’Immigration and Cultural Communities (MICC)
Ministry of Education, Recreation and Sport (MELS) / Private company (specify): / Others (specify):
Person contacted: / Person contacted: / Person contacted:
Organization: / Organization: / Organization:
Telephone number: / Telephone number: / Telephone number:
1. RESEARCH, STUDY OR STATISTICS
1.1. Purpose of researchDescribe the research objectives (attach research protocol or abstract ):
1.2. Research stages
Describe, in chronological order, the different stages of your research. Also indicate if you plan on publishing scientific articles:
1.3. Size and characteristics of the study population
Define the size of the study population and describe its characteristics (e.g..: participants’ gender, age group, regions, periods of interest, etc.):
2. PERSONAL INFORMATION REQUESTED
2.1. Identify the requested information and specify the data extraction periodsReproduce the following table and list all requested personal information, justify their necessary for the research and identify the data extraction periods.
If this is a modification request, list all the information needed.
Data Custodian / Database’s name / Variable’s name / Variable’s format* / Justify the necessity** to obtain this information in this specific format for your research / Data extraction period***
(Enclose to your application the data extraction quote from the Data Custodian or any other relevant document.)
* Variable’s Format examples: Dates (YYYY/MM, YYYY, etc.), Postal code (3 characters), Age by intervals of 10 years, Weight by intervals of 5kg, etc.
** Necessity means that your research cannot be completed without this information.
*** There is a difference between the Subject selection period and the Data extraction period. For instance:
Subject selection: 35-50 y-o female patients who have had surgery X between 2000/04/01 and 2005/03/31.
Data extraction period: 1 year before and 3 years following the surgery’s date.
2.2. Justification of the need to receive the requested personal information
For each information requested in section 2.1, justify its necessity for this study:
2.3. Pairing of Information
Will the information provided for this research be matched to other personal information? If yes, explain. (e.g..: medical files, questionnaires, etc.):
3. CONSENT
4. TRANSMISSION AND PROTECTION OF PERSONAL INFORMATION
4.1. Medium and transmission methodSpecify the medium used by the Data Custodian(s) for transmitting the requested information:
Paper CD/DVD USB key/ Removable medium Secure link Others, specify:
Specify the transmission methodof the medium: : Registered mail E-mail FTP RTSS
Others, specify:
Will the information transmitted be encrypted? : Yes Encryption method:
No
Other relevant information:
4.2. Security measures related to data processing and storage
Indicate where information will be stored (rooms, offices) :
Physical security
Please identify the security measures in place to protect access:
Offices: magnetic card Workstations: password Medium used: locked filing cabinet
key others: password
security agent others:
others:
Will the information stored be encrypted?
Yes No
Storage of authorized personal information for the duration of its use (check all applicable choices):
server (network) independent laptop independent office computer removable medium ( USB key, external drive, etc.)
others; specify:
Main work station:
Office computer Laptop
Is the computer equipped with protection?: No Yes Please detail:
Who will have access to the personal information?:
5. STORAGE AND DESTRUCTION
5.1. Storage periodSpecify the expected date of destruction of the personal information received as per this application:
year-m-d
5.2. Method of information destruction
Please identify the methods of personal information permanent destruction once the research is completed:
Shredding Demagnetization Physical destruction of medium File deletion Emptying trash
Use of a specialized application (specify) :
Managing backup copies
Person in charge:
Date of backup copy destruction:
year-m-d / Please indicate who will be in charge of destroying the authorized personal information
Outside firm:
In-house resource :
COMMITMENT TO CONFIDENTIALITY
To ensure that your application is processed within a reasonable time, please make sure you attach the following documents to your completed application:
Check if included N/A[1]
Copy of a research protocol or an abstract
Copy of the participants consent form
Copy of the approval letter from a Research Ethics Committee
Authorization of the manager of Professional Services in a health centre
Confidentiality commitment from the research team members
Copy of a quote from the Data Custodian
After reading each item, the signatories must affix their initials in the right hand column
Should the Commission authorize this request, I formally commit to: / InitialsAlways ensure the privacy of information communicated, regardless of the medium on which it will be held
Build a list of research team members who will have access to the provided information and have them sign an indefinite confidentiality agreement
Not publish or transmit any information that could indirectly identify a person
Take all security measures aimed at protecting authorized access to information, including prohibiting the disclosure of personal information to third parties and limiting its duplication
Only use authorized information for the purposes for which the authorization is granted. Consequently, any use for other purposes or by another researcher will require a new application to be submitted to the Access to Information Commission
Promptly notify the Access to Information Commission of any change of principal investigator or data storage area
Promptly notify the Access to Information Commission of any breach of confidentiality or any loss or theft of the authorized information
Destroy all information that has been disclosed as part of this application no later than the date established by the Commission in its letter of authorization
Signatures of principal investigator and co-investigators
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[1] Not applicable