HES Application Form, Part 1

Hospital Episode Statistics: HES Data Request Service Application Form, Part 1B

HES Data Request Service

Application Form

Including sensitive or identifiable fields
in your tailor-made report

Part 1B: Details of the applicant

Introduction

This document is Part 1A of the HES Data Request Service Application Form. You can find additional copies of this document, and other documents relating to the Data Request Service, on HESonline [www.hesonline.nhs.uk].

When completing the form, please either type or write in black ink, as this form may be photocopied. If you are returning this form electronically, you will also need to supply a copy by fax or post once your request has been approved, as signatures are required for audit purposes.

Before making an application, please make sure that you have read the accompanying information in the Request a tailor-made report area of HESonline website [http://www.hesonline.nhs.uk].

Special note

In completing this application form, applicants are signing to confirm that they have read and understood the HES Protocol and HES User Guide (copies are available on HESonline).

Please keep a copy of all the documents, including completed forms, for your own records.

Service type

Which type of tailored report do you want? Please refer to the guidance at the Request a tailor-made report area of HESonline [http://www.hesonline.nhs.uk]. Please note there a much quicker and easier application process if a summary table with no sensitive data (which includes small numbers) meets your requirements.

Please select from the following report options:
Tailored summary tables including sensitive data
Episode records
Episode records including sensitive data
Patient-identifiable episode records
http://www.hesonline.nhs.uk / Published October 2010 / Page 2 of 7

Hospital Episode Statistics: HES Data Request Service Application Form, Part 1B

Details of the applicant

Previous HES use
Is this request: an update of an earlier extract or a new application? / Update
New
If you have requested the HES patient identifier (extract_hesid) and require this to be encrypted using the same key as a previous extract, please enter the extract specification reference number (ETxxxx)
Please provide copies of any existing data sharing agreements. / ET
Additional Data Linkage
If you have a particular cohort of patients that you want to identify in the data (using NHS number or other patient identifiers) then that would most likely require our Trusted Data Linkage Service (TDLS). If you are not asking us to identify a cohort of patients or link patients across time or datasets then it is likely that the request will fall within the standard HES extract service.
The data I am requesting requires additional data linkage
Contact details
Name: / Title (Mr, Mrs, Ms, Dr, etc):
Organisation name:
Address:
Postcode:
Telephone:
Fax:
Email address:
Signature:
Delivery address (if different from above)
Name: / DELIVERY Address
Organisation:
Tel:
Fax:
E-mail:

Other users – Every person using the record level data must be listed in this section. (Please continue on an additional sheet if necessary)

Name / Organisation (if different) / Signature / Date

Organisation type (Please tick to indicate your organisation type)

Academic Institution
Commercial
Commercial (Pharmaceutical)
Academic Institution Department of Health
Academic Institution Healthcare Products
Insurance
Marketing
Media / NHS Trust/PCT
NHS Other
Other Government Department
Research
Solicitors/Legal
Student/Individual
The NHS IC
Other (please specify)
Data Re-use Statement
Please indicate using the options below, the use to which you intend to put the requested data (please select all the relevant options):
Please confirm the “Territory” that you wish to utilise the data in the end use of products or services supplied by you.
*Please note that we may require further information for requests to utilise the data outside of England. / England
UK*
Europe*
Worldwide*
To be used internally by your organisations for its own internal business purposes
To be used by your organisation as part product or service to be sold by you to your customers
To be used as part of a publicly funded research project
To be used as part of a commercially funded research project
To be used by your organisation as part product or service given freely by you to your customers
To be used as part of a publicly funded publication or news channel
To be incorporated into a publication which will be subsequently advertised for sale
To be incorporated in to a publication which will be subsequently distributed free of charge
To be used by a private individual for academic purposes
If you wish the Licencee of this agreement to be named as a University or Academic Institute, please provide confirmation that you have the required authority to enter a contractual agreement on the behalf of this Institute. Alternatively, please state if you, the individual should be named as the Licencee.
Licencee of this requested data: (please confirm)
Please specify any additional intended usage for this data:
Data retention, storage and destruction
(i) How long do you wish to retain the data?
If longer than 12 months, please justify your reasons below (the maximum data retention period is 3 years, with a review annually). / yrs mths
Please tick the boxes below to confirm you will store, retain and destroy the data appropriately.
Storage
Data will be stored on a secure system password protected where by access to the HES data is restricted to only those who are named within this agreement.
Retention
Data will be retained until the date agreed with the NHS IC. If data is required for longer, approval from the NHS IC will be obtained.
Destruction
Data will be securely destroyed using file shredding software. Similarly, physical media will be destroyed using a high specification shredder with the functionality to irreversibly destroy the disc. The data will also be removed from any back up tapes that contain it. Confirmation that this has occurred will be given in writing to the NHS IC.

Details of Data Custodian / Caldicott Guardian (for NHS organisations)

Name (please type or print): / Title (Mr, Mrs, Ms, Dr, etc):
Status/position:
Organisation:
Address: / Address where data to be held (if different):
Telephone: / Mobile (optional):
Fax: / E-mail:

Declaration:

I, the Data Custodian / Caldicott Guardian named above, will ensure that any published results using HES data will adhere to the HES Protocol and the terms and condition of the agreed data sharing agreement. I have also read, understood, and will follow the general terms and conditions given at the start of this document.
Signature: / Date:
Request for sensitive data items
If you need access to sensitive data items then please list them here, along with a reason for requesting access to each item.
Full justification for the requirement of each sensitive data item, and how each item is to be used is required. This information will be used to justify your request to the DMsG if you do not already have approval. Failure to fully detail your requirements will result in a delay with your application.
If you require access to sensitive fields have you got valid consent? (please provide a copy of your consent form along with your application)
If you do not have valid consent have you got approval from the Database Monitoring sub Group (DMsG) (please provide your relevant DMsG ref number and letter of approval)
Please note, if you do not have DMSG approval the NHS IC will facilitate the approval process on your behalf.
Please provide a copy of your System Level Security Policy (SLSP) a link to the template document can be found at http://www.nigb.nhs.uk/ecc/applications
Section 251 of the NHS Act 2006 Applicable for Access to Identifiable data items
If you require access to Identifiable fields have you got valid consent? (please provide a copy of your consent form along with your application)
If you do not have valid consent have you applied for the support of Section 251 of the NHS Act 2006? (originally enacted under Section 60 of the Health and Social Care Act 2001) Please provide your ECC reference number and your approval letter.
For access to Identifiable data please note your application will not be processed by the NHS IC without either valid consent or Section 251 approval being in place upon application.
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