Request for Confidential EMS/Trauma Registry Data

Request for Confidential EMS/Trauma Registry Data

Texas EMS/Trauma Registry

Request for Confidential EMS/Trauma Registry Data

And Usage Agreement

Texas EMS/Trauma Registry

The Department of State Health Services

1100 W. 49th Street

Austin, Texas78756

512-458-7266

Background: The Texas EMS/Trauma Registry (TTR) prefers to review and comment on EMS/Trauma confidential data requests prior to the Texas Department of State Health Services, Institutional Review Board (DSHS-IRB) submission. This review ensures that the researcher does not have to go through the DSHS-IRB process, only to learn afterward that the data is not available. It also enables any feedback that the TTR may have about a particular study to be addressed prior to the formal DSHS-IRB review.

Instructions: Before submitting a TDH-IRB application, please complete and return this form to the Texas EMS/Trauma Registry. Attention: Linda Jones, MSPH, Manager, at the address listed above.

  1. Name and address of the agency, institution, or firm conducting the study.
  1. Name, degree(s), title, address, and phone number of person who will direct the study.
  1. Names, degree(s), and titles of other persons who will be requesting the data from the Texas EMS/Trauma Registry.
  1. Title of Study.
  1. State the purpose of the project.
  1. Summarize the study design and methods (i.e., case-control, cohort, etc.).
  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?

Complete the Data File Order Form, the Data Usage Agreement, and the EMS and/or Hospital Variable Checklist (s).

Texas EMS/Trauma Public Access File

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 Access File

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.

Destruction Method / Select Method / Estimated
Completion Date
Delete files from all storage media and return the disk to Texas EMS/Trauma Registry
Delete files from all storage media and use a disk shredder (or the like) to shred the disk
Principal Investigator /study center:
Initials:

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.

Signed: / Date:
Name:
(Public Access file will be sent to the individual who signed the Data Usage Agreement)
Title:
Organization:
Address:
City: / State: / Zip:
Phone: / Fax: / Email:

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

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