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Department of Health and Social Services (State of Alaska)

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File type: PDF

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Department of
Health and Social Services
DIVISION OF PUBLIC HEALTH
Section of Chronic Disease Prevention and Health Promotion
3601 C Street, Suite 722
Anchorage, Alaska 99503
Main: 907.269.2020
Fax: 907.269.5446
Data Use Agreement
The Alaska Section of Chronic Disease Prevention and Health Promotion (CDPHP) places the following
conditions on the acceptance and use of (dataset/program name) data collected
and maintained by CDPHP:
(primary applicant name) located in
(organization/agency name) (Recipient) will have access to the data for
public health purposes or for research as defined on the attached data request. If individuals with access to
the data change due to staffing transitions or changes in employment status, CDPHP will be notified and
new contact information will be provided. Other persons may have access to the data only for technical
support and with prior approval from CDPHP.
Initial each item (primary applicant only).
“Ownership” of the data set remains with CDPHP. Under Health Insurance Portability and Accountability
Act of 1996 (HIPAA), the individual or patient is the owner of his/her data; all others have limited rights of
use. When the proposed analyses are completed, all copies of these data will be destroyed (confirmed in
writing), or returned to CDPHP. If return or destruction is not feasible, Recipient must explicitly state this in
the Data Use Agreement (DUA) to extend protections required in this DUA to that data as long as Recipient
is in possession of it, and notify CDPHP in writing.
Recipient shall use appropriate safeguards to prevent use or disclosure other than as provided in this
DUA, including complying with HIPAA.
Recipient may not release data obtained--in whole or part--to any person other than those listed in this
DUA without the express written permission of the CDPHP Deputy Section Chief. Recipient shall include a
disclaimer that expressly credits any analyses, interpretations, or conclusions reached to the author(s) and
not to CDPHP, unless prior authorization has been obtained, in all publications, presentations, and
communications that refer to data defined by this DUA.
Recipient shall protect the identity of individuals whose information is in the dataset. (Although names
may not be provided, in some communities, the dates, age, sex, race and place may be sufficient to identify
an individual.) Recipient may not use the identity of a person discovered inadvertently.
Recipient shall immediately disclose to CDPHP any use or disclosure not provided for in this DUA which
it becomes aware of. Recipient shall cooperate with CDPHP in responding to and mitigating any
unauthorized use or disclosure.
The Recipient and any associate with access to the data set for analysis purposes acceptable as part of
this data request shall submit to the CDPHP Deputy Section Chief a signed DUA. If it is not feasible for all
members of the research team to sign, the Primary Applicant listed on the DUA is responsible for ensuring all
members of the team respect and follow the conditions as outlined in the DUA, and they must initial a
statement acknowledging they accept this responsibility. If a need exists to utilize the data past the end date
indicated on the Data Request, a new DUA must be signed.
Recipient may use data only for public health research, public health program evaluation, or public
health planning purposes, as described in the attached data request form. Recipient may not use or
further disclose data in a manner that would violate HIPAA or this DUA.
Recipient shall submit publications arising from the analysis of the requested data to the CDPHP
Deputy Section Chief at least two weeks prior to dissemination. This is to ensure correct interpretation of
the data. If disagreement exists, the Recipient shall allow CDPHP the opportunity to include comment
within the published document. Acknowledgment is to be given to CDPHP as the source of data in any oral
or written presentations of the results. Recipient shall notify CDPHP upon final publication of an article or
report and provide the publication’s suggested citation.
I have read and agree to the above conditions of use for data from the Alaska Section of Chronic Disease
Prevention and Health Promotion. By signing, I also agree to observe HIPAA privacy and confidentiality rules
and regulations.
Primary Applicant Name:
Telephone/Fax:
E-mail Address:
Date:
Signature:
Affiliation:
**Primary Applicant is signing on behalf of all co-investigators and acknowledges responsibility for ensuring
co-investigators will follow the above conditions for use of data and will observe HIPAA privacy and
confidentiality rules and regulations. If applicable, Primary Applicant must initial here:
Additional individuals with access to the data (add lines for additional people as needed)
Name: Signature:
Name: Signature:
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Alaska Behavioral Risk Factor Surveillance System (BRFSS) Data Request
BRFSS Data Request
Requestor Information
Project Title:
Organization/Agency:
Principal Investigator Name:
Additional Authorized Users: Request Date:
Required Date:
Dataset Information
1. Proposed use of data and methods of analyses: 2. Time period selection:
(Data are available from 1991 onward – please specify all years for
which data are being requested.)
3. Topic(s): Please select specific topics of interest. (NOTE: Data may not be available for all years requested.)
Quality of life
Risk factors
Preventive factors
Disability
ACEs
Alcohol counseling
Nutrition counseling
General health
Alcohol use
Cancer screening
Obesity attitudes
Healthcare access
Cardiovascular risks
Cancer survivorship
Oral care
Healthy days (physical and mental)
E-cigarette use
Cardiovascular care
Other screening
Sleep
Exercise habits
Diabetes care
Physical activity attitudes
Chronic Disease
HIV risks
Exercise counseling
Quality healthcare
Arthritis
Injury risks
Health screening
Tobacco attitudes
Cancer
Interpersonal violence
HIV screening
Tobacco cessation
CVD
Marijuana use
Immunizations
Vision care
COPD
Nutrition habits
Nutrition attitudes
Diabetes
Overweight/obesity
Kidney disease
Suicide ideation
Mental health
Tobacco use
Oral health
Tobacco smoke exposure
Vision
Other indicator(s) not listed:
COMPLETE DATASET(S)
Alaska Behavioral Risk Factor Surveillance System (BRFSS) Data Request
BRFSS Data Request
4. Crosstab(s) to be provided (when n is sufficient):
Income
Race
Geographic Region(s):
Other:
5. Data Format(s):
SPSS statistical software (.sav file):
*recommended format
SAS Statistical software: Other (please specify):
6. Additional information, requirements, or questions (if any):
CDPHP USE ONLY
*A signed Data Use Agreement must be received prior to sharing data.
Request Approved:
*Conditions of approval attached, if applicable.
Request Denied:
*Reasons for denial attached.
Name of Reviewer: Date:
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Department of Health and Social Services (State of Alaska)

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Completed 21 January 2021

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