Data Access Request Form v1.0 Page 1 of 5
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Data Access Request Form
This form is designed to facilitate requests for access to institutional data by internal and external applicants.
Any individual or group that would like to use Michener’s institutional data for scholarly activity, publication
or presentation must complete and submit this form for review and approval by Michener’s Data Access
Review Committee.
Instructions for Applicants:
Ensure all sections of this form are completed before submitting it to the Applied Educational Research
Include any supporting documents with your submission that is related to the request (e.g. ethics
approval, research abstract, etc…)
Send completed form and any supporting documents electronically to
Section A: Applicant Information
Full Name:
Position Title:
Organization / Educational Affiliation:
Mailing Address:
City, Province & Postal Code:
Section B: Division / Department Approval (to be completed by internal applicants)
Michener applicants are required to obtain approval from their Chair/Supervisor before submitting
this form.
Has approval been granted from Chair or Supervisor to use institutional data? Yes No
_________________________ _________________________ ______________
Name of Chair/Supervisor (print) Signature of Chair/Supervisor Date
For Data Access Review Committee use only:
Reference #: _______________________________________________
Date Submitted: ____________________________________________
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Section C: Data Request Details
1) Is the request for data in support of your academic training program? YES NO
If yes, please indicate the applicable program:
Post-Doctoral Masters Resident/Clinical Fellow
PhD Undergraduate Other, please specify ______________________________
2) Description of Data
a. Please describe the data you wish to access, including all relevant details about the scope of the data
b. By when do you wish to receive the data? (Please specify date or approximate timeframe.)
3) Please specify in which department(s) the data requested is located or stored.
4) a. Please state the research question that the requested data will help you examine.
b. Please state the hypothesis or hypotheses that the requested data will help you examine.
5) Will the requested data be combined with other sources of data for this project? YES NO
If yes, please describe (a) the other data you plan to access, (b) how it will be combined, and (c) from
where the other data will be obtained.
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Section D: Research Ethics Approval (this section only applies to research projects)
6) Has this project been approved by a Research Ethics Board (REB) other than Michener’s REB?
If yes, please provide a copy of the approval letter upon submission of this form.
If no, will you seek approval from a Research Ethics Board other than from Michener’s REB?
Please use the space provided to provide any clarification about your plans regarding ethical review that
may be helpful to the Committee. _________________________________________________________
Section E: Publication / Dissemination of Results
7) Please list all individuals or groups with whom the requested data will be shared.
8) Will the requested data be used in any publication or presentation? YES NO
If yes, select all that apply from the list below.
Dissertation or Thesis
Conference poster, presentation or proceedings
Lecture or workshop
Journal article (paper or online)
Books, monographs or abstracts (paper or online)
Internal publication or presentation only (not for audiences external to my organization)
Other, please specify _________________________________________________________________
9) Is a project abstract or description included with this submission? YES NO
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10) Peer Review Process Through Michener’s Data Access Review Committee (DARC)
If access to the data requested in this form is approved, you will be required to submit your manuscript
(article, presentation, etc.) for peer review by Michener’s DARC at least 5 business days before the
intended presentation or publication.
Please specify the date below that you expect to submit your presentation or manuscript for Michener
peer review.
Date of Submission for Michener Peer Review: ____________________________________________
Date of Intended Presentation or Publication: _____________________________________________
11) Please indicate whether or not you will identify the Michener Institute in your research as the source of
the data requested, and briefly explain why you plan to identify or not identify Michener.
Section F: Applicant Agreement and Signature
12) Applicant Agreement
I agree to the following conditions with regards to access to the data requested in this form, if approved by
Michener’s Data Access Review Committee (DARC).
a) The data requested will be used only for the project or purpose outlined in this request form and
only published, presented or disseminated as outlined in this request form. I understand that if I
should wish to use the requested data in the future for some other project or purpose or to publish,
present or disseminate it in ways other than specified in this request form, I must submit a new
request form to Michener’s DARC to seek approval.
b) I understand that any proposed research involving human participants carried out at or in
collaboration with The Michener Institute must be reviewed and approved by Michener’s Research
Ethics Board (REB) before the research can begin. I understand that if the data requested in this form
pertains to Michener faculty, staff or students or other individuals associated with Michener, I must
submit an application to Michener’s REB to obtain approval to conduct my proposed research using
the data requested in this form. Approval to access to Michener’s data by the DARC does not
constitute permission by Michener’s REB to conduct the proposed research outlined in this form.
_______________________________ _______________________________
Applicant Signature Date
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Questions about completing this form can be directed to:
Sherryl Dizon, Data Coordinator
Applied Educational Research Office
Telephone: (416) 596-3101 ext. 3438