Requests for de-identified data Survey

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Requests for de-identified data

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Consultative Council on Obstetric and Paediatric Mortality and Morbidity (CCOPMM)
Victorian Perinatal Data Collection (VPDC)
Victorian Birth Defects Register (VBDR)

Request details

1.	Date of request*
	dd/mm/yyyy

2.	Name of requesting person*

3.	Organisation*

4.	Position/Job title*

5.	Contact phone number*

Address*

Street
Suburb/Town
State
Postcode

7.	Email*

8.	DHS employee?*
	Yes No

9.	Reason for request*
	Research project
	Departmental report
	Student (Eg PhD, Masters etc)
	Other, please specify

10.	Data requested*

11.	Time period of interest*

12.	Format in which data are required*

13.	Is identifying information required?*
	Yes No

14.	If you answered yes to the above question, specify why and consult Section 6 of the Health (Consultative Council on Obstetric and Paediatric Mortality and Morbidity) Regulations 2002.

15.	What is the purpose of this study?*

16.	What methodology will be used in this study?*

17.	Which (if any) other data collections are being used in this study?

18.	If for research purposes, has approval been given by the DHS Ethics Committee (or another ethics committee)? *
	Yes No

19.	If you answered no to above question, will the project be submitted to the DHS ethics committee (or another ethics committee)? *
	Yes No

20.	To whom and how will this information be disclosed/disseminated?* Please note: All publications must be endorsed by CCOPMM prior to release and carry the appropriate citation.

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For general enquiries to the Department of Health telephone 61 3 90960000