HomeMy WebLinkAboutData Sharing AgreementKittitas County
Review Form
Grants & Contract Agreement
Today's Date
11/20/2018
Fund/Department
116 -Public Health
Contract/Grant Information
Contract /Grant Agency: Data Sharing Agreement
Period Begin Date: 01/01/2019
Total Grant/Contract Amount: None
Agenda Date
r
1 -
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Period End Date: 12/31/2019
Grant/Contract Number:
Contract/Grant Summary:
The Washington State DOH 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
F_ -
Department Head Signature:
Administrator Date:
Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment:
APPROVED AS TO FORM:
Signature of Prosecutor's Office Date
Signature of Auditor's Office
Date
Signature of Board of Health member Date
Financial Information
Total Amount $
State Funds $
Federal Funds $
Percentage County Funds
Matching Funds $
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:
et Information
Budget Amendment Needed? Yes ❑ attach budget form
New Division Created? 1
Revenue Code
Pass Through Information
Agency to Pass Through I
Amount to Pass Throu
Sub -Contract Approved
Date:
No ❑ Why not
Prosecutor Review
Has the Prosecutor reviewed this agreement? Yes ❑ No ❑
County Departments Impacted
Auditor Facilities Maintenance
Information Services Human Resource
Prosecutor Treasurer
Submitted
Signature:
Department:
nment of Tracking Information
Auditor's Office
Human Resource
Prosecutor's Office
Who Signed the grant application
Reviewer Date
Grant/Contract Review Page 2
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DOH 422-113 August 2017
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.DataRe uests doh.wa. ov.
NOTE. Information on this sheet will be directly copied into the Data Sharing Agreement.
For descriptions of the available data sets, see:
http://www-doh.wa.gov/DalaandStatisticMRepo italS tatisticsData/OrderDataF- iles. aVx
Data user's name and email address: Am to Fuller <am .fuller co.kittitas.wa.us>
Check the data set(s) you are requesting:
® CHARS N 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 LVashiu ton State institutional Review Board.
Describe in detail how the data will be used and any provisions for re -disclosure. Please_ include the length of
time you will need 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, as well as mortality rates and fertility data.
There may also be intermittent access to general hospitalization rate data, BUSS data and vital
records data to inform annual updates to community health data and grant app]
DOH 422-113 August 2017
I'Veal th
DOH 422-113 August 2017
Center for Health Statistics
P.O. Box 9709
Olympia, WA 98504-9709
360-236-4310
Business Contact Name
Tristen Lamb
Title
Interim Public Health Administrator
Address
507 Nanum St. Suite 107, Ellensburg, WA 98926
Telephone #
509-962-7003
Email Address
amy.fuller@co.kittitas.wa.us
Data User Contact Name
Amy Fuller
Title
Assessment Coordinator
Address
507 Nanum St. Suite 107, Ellensburg, WA 98926
Telephone #
509-962-7002
Email Address
am .fuller co.kittitas.wa.us
IT Security Contact Name
Jim Goeben
Title
IT Director
Address
205 W 5th Ave, Ellensburg, WA 98926
Telephone #
509-312-0213
Email Address
jim.goeben@co.kittitas.wa.us
Privacy Contact Name
Candi Blackford
Title
Administrative Supervisor
Address
507 Nanum St. Suite 107, Ellensburg, WA 98926
Telephone #
509-962-7515
Email Address
candi.blackford@co.kittitas .wa.us
Ota user Conlaet: the person who will receive the data
Business Contact: 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.
1T 5ecur4y Contact: a person with responsibility for ensuring data are stored and transferred in accordance with federal and state laws and
regulations.
Privacy Contact: a person with responsibility for privacy/public disclosure requests; ensuring compliance with HIPAA; ensuring data are
maintained in accordance with federal law.
DOH 422-113 August 2017