Data Request Form - Office of Safety and Quality in Health Care数据请求形式的医疗品质与安全办公室.docVIP

Data Request Form Attachment A SECTION 1: REQUESTOR DETAILS Name Contact Number Position Work Location Email Contact Recipient Name (if not the same as the requestor) Contact Number Position Work Location Email Contact Urgency (Please circle. Please allow sufficient approval process time) Urgent: 1-10 Working days Semi-Urgent: 11-30 Working Days Non-Urgent: 31 + Working Days Information/Data Collection(s) Reason/Purpose (what the information/data is required for) Description of Information/Data Required (Please include data items/variables required using the Data Field Guides) Reporting Period Required Details as to how the data will be used List all persons who will have access to the data Data Retention Period Frequency (Circle as appropriate) One off Request Date Required Fortnightly Monthly 6 Monthly Annually Ongoing Other (please specify) Requestor Signature Date SECTION 2: APPROVAL DETAILS Request Number Date Received Comments (Discussion with requestor – revisions required? Agreement to proceed? Can data be provided?) Data Custodian Recommendation Approved Not approved Data Custodian Signature Date Approval Status* (To be completed by Data Steward) Approved Not approved Data Steward Signature Date SECTION 3: COMPLETION DETAILS Date Completed Date Provided Revisions Required Feedback/Comments Please scan and email this form to Data Custodian, Director, Patient Safety Surveillance Unit, Performance Directorate. For any data request queries please call 9222 0294. Data Steward approval is required for any data extraction request or request from non WA Health person. TO BE COMPLETED BY THE PERSON EXTRACTING DATA Request Number Date Description of Data Request Data Supplier Name Contact Number Position E-mail Contact Reporting Definition or data extract criteria used (e.g., inclusions and exclusions – supply locati