Get Doh-5132. Sparcs Limited And Identifiable Data Request Form - Health Ny

The DOH-5132 form is essential for requesting limited and identifiable data from the New York State Department of Health. This guide provides clear and comprehensive instructions for users to complete the form online effectively, ensuring all necessary information is included.

Follow the steps to successfully submit your data request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the organization and individual requesting the use of data section. Include the project director’s name, title, phone, and email. Then, provide the organization name and address, detailing the specific department or unit. If different from the project director, include the contact person's details.
3. Indicate the type of requestor by checking all applicable boxes, such as student researcher or non-profit organization, and include additional information if necessary.
4. In the nature of request section, provide the title of the project and the primary reason or purpose for the data request. Check all applicable types of request related to healthcare.
5. Specify the data requested by listing the type and years. Indicate if periodic updates of the dataset are necessary and select the frequency.
6. If requesting identifiable data, address sections related to HIV/AIDS and abortion records, including justification for any non-redacted records.
7. For identifiable requests, indicate if you have obtained Internal Review Board approval and provide the details as instructed.
8. Describe the research methods, small cell size policy, and linkages to other datasets in the summary of proposal section.
9. In the confidentiality of data section, detail the safeguards for maintaining data security and identify any external project partners.
10. Complete the data use agreement section, listing individuals who will have access to the dataset, and clarify any intent to disseminate or re-release data.
11. Signatures section requires the project director and an organizational representative to sign and attest that the data will be used responsibly and in accordance with the application.
12. Once completed, save your changes, download, print, or share the form as necessary.

Take the first step and complete the DOH-5132 form online today!