HomeMy WebLinkAboutData Sharing Agreement Info SheetDOH 422-113 August 20 I 7
Data Sharing Agreement Information Sheet
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98504-9709
360-236-4310
A Data Sharing Agreement (DSA) with the WA State Department of Health is required to receive Comprehensive
Hospital Abstract Reporting System (CHARS), Birth, Fetal Death, Linked Birth-CHARS, and Linked Birth-Infant
Death data files. To start the data sharing process, fill out this information sheet, then email to
CHS.DaiaR ~q u.est-.@doh.wa .goy.
NOTE: Information on this sheet will be directly copied into the Data Sharing Agreement.
For descriptions of the available data sets, see:
llltp://ww, .do IL wa. gov/DataandS tal i licalRepor
Data user's name and email address: Amyta Fuller <amy.fuller@co.kittitas.wa.us>
Check the data set(s) you are requesting:
~ CHARS ~ Birth ~ Fetal Death ~ Linked Birth-CHARS ~ Linked Birth-Infant Death
This agreement is to receive limited unidentified data. If your purpose is to re-identify or contact individuals or link
to other data you will need approval from the Was hin gton State Institutional Review Board.
Describe in detail how the data will be used and any provisions for re-disclosure. ~e ase incJude the length o f
time .you will ne ed the data:
Data will be used to inform community health assessment reports, which occur on a 3 to five year
cycle. No confidential information will be shared; the only data that will be utilized is general
population measures, sorted by demographic category. There may also be intermittent access to
general hospitalization rate data, or death/birth data to inform grant applications as well.
DOH 422-113 August 2017
DOH 422-1 13 August ~o 17
Business Contact Name
Title
Address
Telephone#
Email Address
Data User Contact Name
Title
Address
Telephone#
Email Address
IT Security Contact Name
Title
Address
Telephone#
Email Address
Privacy Contact Name
Title
Address
Telephone#
Email Address
Data User Conlact : the person who will receive the data
Amy Fuller
Assessment Coordinator
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98504-9709
360-236-4310
507 Nanum St. Suite 107, Ellensburg, WA 98926
509-962-7003
robin.read.@co.kittitas.wa.us
Amy Fuller
Assessment Coordinator
507 Nanum St. Suite 107, Ellensbur_g;, WA 98926
509-962-7002
amy.fuller@co.kittitas.wa.us
Jim Goeben
IT Director
205 W 5th Ave, Ellensburg, WA 98926
509-312-0213
jim.goeben@co.kittitas.wa.us
Candi Blackford
Administrative Supervisor
507 Nanum St. Suite 107, Ellensburg, WA 98926
509-962-7515
candi.blackford@co.kittitas .wa.us
Business Contncl: a person with authority to sign the agreement for entire agency or organization. The Business Contact will be responsible for
maintaining a signed Appendix A for all individuals who have access to the data file(s). Appendix A forms are available upon request.
IT . cc urily Contact : a person with responsibility for ensuring data are stored and transferred in accordance with federal and state laws and
regulations.
Privacy ·C o ntaot: a person with responsibility for privacy/public disclosure requests; ensuring compliance with HIP AA; ensuring data are
maintained in accordance with federal law.
DOH 422-113 August 2017
Kittitas County
Review Form
Grants & Contract Agreement
Today's Date Agenda Date ~,~ July 7, 2018
Fund/Department
116-Public Health
Contract/Grant Information
Contract /Grant Agency: Washin gto n State Department of Health Data Sharing Agreement
Period Begin Date: Upon Signature j I Period End Date: December 31, 2018
Total Grant/Cont ract Amount: None
Grant/Contract Number:
Contract/Grant Summary:
The Washington State Department of Health Data Sharing Agreement is established to allow the health
department to share data in regards to Comprehensive Hospital Abstract Reporting System (CHARS),
Birth, Fetal Death, Linked Birth-CHARS, and Linked Birth-Infant Death data files.
Recommendation for Board of Health and Board of Health Review on
Date: 0 /J0 /f fJ
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROV DAS TO FORM:
Date
1 r tit >
Date
Signature of Board of Health member Date
Financial Information
Total Amount$ State Funds $ Federal Funds $
Percentage County Funds Matching Funds$ I CFDA#
In-Kind$
Explain
Grant/Contract Review Page 1
Is Equipment being purchased? Who owns equipment?
New Personnel being hired? Contact HR hiring -reporting requirements
Future impacts or liability to Kittitas County:
Budget Information
Budget Amendment Needed? Yes D attach budget form No • Whynot
New Division Created?
Revenue Code
Pass Through Information
Agency to Pass Through
Amount to Pass Through $
Sub-Contract Approved Date:
Prosecutor Review I Has the Prosecutor reviewed this agreement? I Yes • No D
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted I Signature :
Department:
I Date:
Assignment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
I Reviewer I Date
Grant/Contract Review Page 2