Administrative Health Data, Data Request Application

Alberta Health

Section 1: Application Details

Request Type

☐ Research (Research studies with approval from a research ethics board)

☐ Information (Information to support planning, policy development, quality improvement projects)

Request Type

☐ New

☐ Update (add additional fields or years of data to previously disclosed data)

☐ Re-use (use previously disclosed data for a different project)

Previous Request Information

(For Update or Re-use Requests)

Request Number: / Project Name:

Key Contact/Principal Investigator

(For Research Requests, this must be individual listed in the ethics board approval)

Last Name: / First Name: / Title:
Phone: / Email:
Institution Name: / Position:

Secondary Contact

(If different from above – contact person for correspondence, administrative purposes, etc.)

Last Name: / First Name: / Title:
Phone: / Email:
Institution Name: / Position:

Project Details

Project Name:
Project Purpose:

Section 2: Supporting Documentation

Research Requests

Email this application form along with the documents listed below to:

Required Documentation: (Attach the following documents)

☐ Original research proposal

☐ Original ethics submission

☐ Original ethics approval

☐ Preliminary Data Specification (if data elements are known)

(see Overview of Administrative Health Datasets and Commonly Requested Data Elements)

Additional Documentation: (Attach applicable documents listed below)

☐ Revised research proposal

☐ Amending ethics submission

☐ Amending ethics approval

☐ Current ethics renewal approval

☐ Agreement or letter from external data source permitting linkage with Alberta Health data

☐ Consent template/Patient information sheet

Information Requests

Email this application form along with the documents listed below to:

☐ Any relevant project documentation (i.e. project charter)

☐ Preliminary Data Specification (if data elements are known)

Section 3: Data Requested

Datasets:

DATASET: / START DATE:
(MM/DD/YYYY) / END DATE:
(MM/DD/YYYY)
☐ / Alberta Blue Cross Pharmacy Claims
April 1, 1994 onwards
☐ / Alberta Continuing Care Information System (ACCIS)
☐ / Long-Term Care January 1, 2010 onwards
☐ / Community Care* April 1, 2011 onward *Dataset is incomplete
☐ / Ambulatory Care April 1, 1997 onwards
☐ / Inpatient April 1, 1993 onwards
☐ / Pharmaceutical Information Network (PIN) Dispenses
April 1, 2008 onwards
☐ / Population Registry April 1, 1993 onwards
☐ / Practitioner Claims January 1, 1994 onwards
☐ / Vital Statistics with Identifier - Births (with authorization)
January 1, 2005 onward
☐ / Vital Statistics with Identifier - Deaths (with authorization)
January 1, 1999 onwards

Cohort:

☐ Provided By Researcher

☐ Defined Using Alberta Health Data

(see Cohort Template for the format to submit cohort data; note that Secure File Transfer Protocol must be used)