ࡱ>  Tqbjbjqq  -ee=:HH&&&&&$&&&P&(&ď+2(222m6J89pɍˍˍˍˍˍˍ$Dq&6<K6K6"6<6<&&22`(F?F?F?6<R&2&2ɍF?6<ɍF?F?|D 2`m<&<4<ďCPR=*Rh*R&ɂ ::^F?:L1;:::@>:::ď6<6<6<6<R:::::::::H Q%:  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 1B 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 HYPERLINK "https://www.hesonline.org.uk/"HESonline [www.hesonline.nhs.uk]. When completing the form, please either type or write in black ink, as this form may be photocopied. Electronic copies of the application forms are preferred and will speed up the application process. . Before making an application, please make sure that you have read the accompanying information in the Request a tailor-made report area of  HYPERLINK "https://www.hesonline.org.uk/" HESonline website [https://www.hesonline.org.uk]. Please keep a copy of all the documents, including completed forms, for your own records. Please note If you are requesting  HYPERLINK "https://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1378" patient-identifiable fields (linked here), you must either have consent in place or obtain Section 251 Ethics and Confidentiality Committee (ECC) approval prior to submitting your request to the HSCIC. The following link will take you to the National Information Governance Board for Health and Social Care (NIGB) website to apply for this approval.  HYPERLINK "http://www.nigb.nhs.uk/ecc" http://www.nigb.nhs.uk/ecc Please note that this process is not supported by the HSCIC. We will need to know the ECC reference number and have confirmation of your approval prior to processing your application. Service type Which type of tailored report do you require? Please refer to the guidance at the Request a tailor-made report area of  HYPERLINK "https://www.hesonline.org.uk/" HESonline [https://www.hesonline.org.uk ]. Please note there is a quicker and more simple application process if a summary table with no sensitive (unmasked) data meets your requirements. For further information on HES summary tables, this can be accessed by clicking  HYPERLINK "https://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1345" here. Please select from the following report options: *HES Tailored summary tables including Small Numbers (unmasked) data  FORMCHECKBOX  HES Episode records  FORMCHECKBOX  HES Episode records including sensitive data (Requires DAAG or ECC approval)  FORMCHECKBOX  HES Patient-identifiable episode records (Requires ECC approval)  FORMCHECKBOX  Additional Data Items You +1'd this publicly. HYPERLINK "http://www.google.com/" Undo Provisional Monthly Patient Reported Outcome Measures (PROMs) I require the additional linked PROMs data and I have completed and included the PROMs application form.  HYPERLINK "https://www.hesonline.org.uk/Ease/servlet/AttachmentRetriever?site_id=1937&file_name=d:\\efmfiles\\1937\\Accessing\\New%20Tailormade%20(AHES)\\Application%20forms\\HESApplicationForm_AppendixE_V2.1.doc&short_name=HESApplicationForm_AppendixE_V2.1.doc&u_id=9181" \t "" PROMs data request form (152KB)  FORMCHECKBOX  Yes  FORMCHECKBOX  No ONS Mortality Data (ONS) I require the additional linked ONS data and I have completed and included the ONS application form, linked below;  HYPERLINK "https://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1381" https://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1381  FORMCHECKBOX  Yes  FORMCHECKBOX  No Additional Data LinkageIf 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. (Please note the additional data linkage does not include the standard HES linkage with ONS/PROMS data or previously requested HES extracts.)  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf you have ticked Yes, please clarify what data you propose to send to us to perform the linkage. (Please do not send any data at this stage)  FORMTEXT       Details of the applicant Previous HES use Is this request: an update of an earlier extract or a new application?Update  FORMCHECKBOX  New  FORMCHECKBOX 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 FORMTEXT       Contact detailsName: FORMTEXT       Organisation name: FORMTEXT      Address: FORMTEXT       Postcode: FORMTEXT      Telephone: FORMTEXT      Email address: FORMTEXT       Data Delivery address (if different from above)Name: FORMTEXT      Delivery Address Organisation: FORMTEXT       FORMTEXT       Tel: FORMTEXT      E-mail: FORMTEXT       Other users  Every person using the record level data must be listed in this section. (Please continue on an additional sheet if necessary)NameOrganisation (if different)Job Title FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Organisation type (Please tick to indicate your organisation type) FORMCHECKBOX  Academic Institution  FORMCHECKBOX  Academic Institution Department of Health  FORMCHECKBOX  Academic Institution Healthcare Products  FORMCHECKBOX  Commercial  FORMCHECKBOX  Commercial (Pharmaceutical)  FORMCHECKBOX  Insurance  FORMCHECKBOX  Marketing  FORMCHECKBOX  Media FORMCHECKBOX  NHS Trust/PCT  FORMCHECKBOX  HSCIC  FORMCHECKBOX  NHS Other  FORMCHECKBOX  Other Government Department  FORMCHECKBOX  Research  FORMCHECKBOX  Solicitors/Legal  FORMCHECKBOX  Student/Individual  FORMCHECKBOX  Other (please specify)  FORMTEXT       Licensee Confirmation (Please complete the relevant section below depending whether your intended usage of the data is for Academic or Non- Academic use);  Licensee Confirmation  For Academic Use Only (Please complete If you have selected the above Academic Institution or Student/Individual categories; Please leave this section blank and skip to the section below if your request is for not for Academic Use) On requesting this data we will be sending you a contractual Data Re-use Agreement (DRA) If you wish for the Licensee of this agreement to be named as a University or Academic Institute, please confirm that you have the required authority to enter a contractual agreement on the behalf of this Institute. If  Yes , please specify the name of the University/Academic Institute that should be named as the Licensee. Please Confirm; Yes  FORMCHECKBOX  Named Licensee  FORMTEXT       No  FORMCHECKBOX  (See below) If you selected No, then your application will be processed under Private Individual Academic Research use; If this is the case then, you, the individual applicant, should be named as the Licensee for this request. Please confirm this by entering the Individual applicants name.  Please specify the Individual applicant to be named as the Licensee;  FORMTEXT        Licensee Confirmation  For Non Academic Use (Please complete If your request is for not for Academic Use) On requesting this data we will be sending you a contractual Data Re-use Agreement (DRA). Please can you confirm that your requesting organisation (as specified in your above contact details) is a legal corporate entity and is able to enter into this contractual agreement as the named Licensee. Please Confirm; Yes  FORMCHECKBOX  No  FORMCHECKBOX  (See below) If you have selected No, please specify the organisation that should be named as the Licensee for this data request; e.g. the applicants Hosting Organisation. Confirmation of the named Licensee;  FORMTEXT        Territory of Use 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.  FORMCHECKBOX  England  FORMCHECKBOX  UK*  FORMCHECKBOX  Europe*  FORMCHECKBOX  Worldwide* Intended Market of Re-UsePlease indicate using the options below, the market(s) that the requested data will be used / re-used by or supplied for;HSCIC product or service being requested and used by a NHS and Social Care organisation or other public body in pursuance of its own public task objective.   FORMCHECKBOX HSCIC product or service to be used by any organisation for the purpose of improving the quality of healthcare management and service delivery in England and NOT involving a commercial transaction.   FORMCHECKBOX HSCIC product or service to be used by any organisation for the purpose of improving the quality of healthcare management and service delivery in England and involving a commercial transaction.   FORMCHECKBOX  All other intended uses (Including Private sector use)   FORMCHECKBOX  Data Re-use Statement What will the data be used for? Please provide us with details on how this information will be used and the intended end use that the data will be put towards. A full description of the purpose for which access to HES data is required needs to be detailed below. NOTE; Please provide full details in this section, further details may be requested if insufficient information is provided. If this application requires access to sensitive data then this information will also be presented to the Data Access and Advisory Group (DAAG) and so needs to be detailed and clear.   FORMTEXT       Any other details  FORMTEXT        Data retention, storage and destruction(i) How long do you wish to retain the data? (up to a maximum of 36 months for non-sensitive or identifiable data and a maximum 12 months for ONS, sensitive or identifiable data. Data may be retained beyond the specified time periods above subject to a renewal of your agreement) If you require the agreement for longer than 12 months, please justify your reasons below   FORMTEXT       yrs  FORMTEXT       mths   FORMTEXT       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. If you intend to store the data at a different location to the stated delivery address, all HES data must be transferred using a secure trackable / traceable method; Please confirm your intended storage address (If different to the delivery address)  FORMTEXT         FORMCHECKBOX Retention Data will be retained until the date agreed with the HSCIC. If data is required for longer, approval from the HSCIC will be obtained.   FORMCHECKBOX 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 HSCIC.   FORMCHECKBOX  ================================================================== The following sections are to be completed by customers requesting sensitive and/or identifiable HES data only. 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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 Data Access Advisory Group (DAAG) if you do not already have approval. Failure to fully detail your requirements will result in a delay with your application. A list of the sensitive fields can be found by clicking at the link  HYPERLINK "http://www.ic.nhs.uk/services/data-access-advisory-group-daag/hospital-episodes-statistics-hes-applications--sensitive-data"  here   FORMTEXT       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 DAAG (please provide your relevant DAAG ref number and letter of approval) Please note, if you do not have DAAG approval the HSCIC 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;  HYPERLINK "http://www.nigb.nhs.uk/ecc/applications" http://www.nigb.nhs.uk/ecc/applications   FORMTEXT        FORMTEXT        Section 251 of the NHS Act 2006 Applicable for Access to Identifiable data items If you require access to Identifiable fields have you gained valid consent? (please provide a copy of your consent form along with your application) A list of the identifiable fields can be found by clicking  HYPERLINK "https://www.hesonline.org.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1378" here If you do not have valid consent have you gained 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 HSCIC without either valid consent or Section 251 approval being in place upon application.   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