PUDF Usage Agreement

Texas EMS/Trauma Registry

Request for EMS/Trauma Registry Public Use Data File

And Usage Agreement

Texas EMS/Trauma Registry

Texas Department of State Health Services

PO Box 149347, MC 1964

Austin, TX 78714-9347

Phone: 512-776-7220

Email:

Revised: May 2013

Background: The Texas EMS/Trauma Registry (TTR) prefers to review and comment on EMS/Trauma data requests prior to the distribution of the public use data file. This review enables TTR to provide feedback to the requestor regarding the analytical use of the data.

Instructions: Please complete this form and submit to the Texas EMS/Trauma Registry, Attention: Tammy Sajak, Manager, Epidemiology Studies and Initiatives Branch, using the email address or physical mailing address above

In the tables below, indicate which public use data file you would like to receive, including year(s) and file format. Data elements included in the PUDF are listed in documents available on the EMS/Trauma Registry web page.

The PUDF for EMS Run Reports contains data submitted to the EMS/Trauma Registry by EMS firms operating in Texas. Data are available annually.

The PUDF for Hospital Admissions contains data on trauma admissions submitted to the EMS/Trauma Registry by Texas hospitals under Registry Reporting Requirements.

1. Name and address of the agency, institution, or firm requesting the PUDF.

1. Name, degree(s), title, address, and phone number of person who will be working with the PUDF.

1. Names, degree(s), and titles of persons who will be requesting the PUDF.

1. State the purpose of the project.

1. Summarize the design and methods (i.e., case-control, cohort, etc.) that will be used to analyze the data.

1. What steps will be taken to protect the confidentiality of the data?

1. What will be done with the TTR data once the study is complete?

Texas EMS/Trauma Registry Public Use DataFile

Data Usage Agreement

As stated in the Texas Administrative Code (TAC) Title 25, Part 1, Chapter 103, Rule 103.22, the Texas EMS/Trauma Registry will not release or make public information or records relating to any personal injury that can be used to reveal the identity of a patient or health care entity. Any attempt to identify a person or health care entity would be in direct violation of the TAC as well as this data usage agreement. By signing below, the undersigned agrees that the data will not be used to identify any individual or health care entity. Questions regarding the data provided must be directed to the Texas EMS/Trauma Registry.

In the following agreement, the requestor and end-user of the data are referred to as the “researcher.” The researcher gives the following assurances with respect to the use of data sets obtained from the Texas EMS/Trauma Registry:

1. The researcher will not (nor allow others to) release individual patient records, either in part or in their entirety, to any person who is not a member of the research or study group specified below;
2. The researcher will not (nor permit others to) attempt to link records from the Texas EMS/Trauma Registry with personally identifiable records from any other source with the purpose of identifying an individual patient or health care entity;
3. The researcher will not (nor permit othersto) release any information that identifies individuals, directly or indirectly;
4. No follow back of any type will be made to any individual, institution or firm without prior Texas EMS/Trauma Registry and Texas DSHS Institutional Review Board approval.
5. The researcher will not attempt to use (nor permit others to) use the data to identify a health care entity;
6. The researcher will not (nor permit others to) copy, sell, rent, license, lease, loan, or otherwise gain access to the data covered by the agreement to any other person or entity;
7. The researcher agrees to read the User Manual and to understand the limitations of the data;
8. The researcher agrees to the data destruction method indicated below;
9. The researcher will credit the Texas EMS/Trauma Registry as follows for any use or publication of information from this file:

Data source: The Texas EMS/Trauma Registry,

Department of State Health Services

1. The researcher will indemnify, defend, and hold the Texas EMS/Trauma Registry, its members, employees, and the Registry’s contract vendors harmless from any and all claims and losses accruing to any person as a result of violation of the agreement; and
2. The researcher will make no statement nor permit others to make statements indicating or suggesting that interpretations drawn from these data are those of the Texas EMS/Trauma Registry.
3. A copy of the results of the study will be furnished to the Texas EMS/Trauma Registry within 60 days of the completion of the project.

Texas EMS/Trauma Public Use DataFile

Data Usage Agreement (continued)

Data Destruction Method:

By signing this agreement, the undersigned agrees to destroy all data files obtained from the Texas EMS/Trauma Registryupon project completion using one of the following approvedmethods (initial in the box next to the intended destruction method). Notification, either in writing or via email, must be sent to the Texas EMS/Trauma Registry upon file destruction as confirmation of obligation fulfillment.

By signing this agreement, the undersigned understands that this agreement is collected by the Texas EMS/Trauma Registry for each data set acquired by the researcher to assure compliance with the Registry’s confidentiality statutes.

Please note: Data will be shipped to the person who signs this agreement.

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Environmental and Injury Epidemiology and Toxicology Branch

Phone: (512) 458-7266 | Fax: (512) 458-7666