SHS Data Use Request Form

SHS Data Use Request Form

INSTRUCTIONS

Please read the Data Confidentiality Rules then complete the form. Your signature on this form certifies that you will comply with the data confidentiality rules and that you will ensure any other data users on your team will also comply with the confidentiality rules.

Data requests requiring significant processing may be subject to a fee to recoup personnel time and expenses. You will be notified in advance of any fees that must be paid prior to processing the request.

Please email SHS.Ask@odhsoha.oregon.gov with questions.

CONTACT INFORMATION FOR DATA REQUEST

Today's date*

Contact Name*

Email*

Phone*

Organization*

Street Address*

City*

State*

Zip*

Are you requesting ACES data?*

Would you like to hear from a staff member from Maternal and Child health to provide technical assistance for analyzing ACES data?

Yes

Select the dataset(s) you are requesting

Note: Due to confidentiality, SHS and OHT public use datasets exclude identifiers below the county level (district ID and school ID and zip code), as well as height and weight variables (BMI is included in the dataset). Depending on the request, race, gender identity or sexual orientation variables may also be excluded from the dataset.

SHS and OHT Dataset(s)*

Select

If requesting a dataset, what format would you like the file in?*

Select

GOALS OF DATA USE

Study Start Date*

Study End Date*

For what main purpose will you use the requested SHS/OHT data?*

(e.g., regional needs assessment, journal article, community report)

Which variables are you mainly interested in?*

(e.g., 8th grade mental health, 11th grade e-cigarette smoking prevalence, PYD Benchmark)

Study Description*

Please describe any relevant details of your study. You can also attach documents below.

As Principal Investigator or Primary Data User, I certify that I have read and will comply with the data confidentiality rules*

Data Confidentiality Rules

As Principal Investigator or Primary Data User, I certify that I will ensure all data users on my team and under my supervision will comply with the data confidentiality rules*

As Principal Investigator or Primary Data User, I certify that a copy or abstract of any manuscript, report, brief, or other product prepared for public consumption and resulting from the use of these data will be communicated to the SHS program by email at SHS.Ask@odhsoha.oregon.gov*

I understand that I can get technical assistance or ask questions about the data by emailing SHS.Ask@odhsoha.oregon.gov*

Typing my name and email below serves as my signature and certifies my agreement with the above.

Name*

Title*

Email*

Include any supporting documents if applicable. (e.g., IRB, Study description)

Please add your program name to the end of the file name and upload the document.

Drag and drop files here or

Contact

Program Design and Evaluation Services

800 NE Oregon Street, Suite 260

Portland, OR 97232

Email: SHS.Ask@dhsoha.state.or.us

Send me a copy of my responses

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