Form VS 144 Application for California's Birth and Death Data Files for Government Agency Use - California

Form VS144 is a California Department of Public Health form also known as the "Application For California's Birth And Death Data Files For Government Agency Use". The latest edition of the form was released in March 1, 2018 and is available for digital filing.

Download a PDF version of the Form VS144 down below or find it on California Department of Public Health Forms website.

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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION FOR
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR GOVERNMENT AGENCY USE
Application Checklist
“Application for California’s Birth and Death Data Files for Government Agency Use”
filled out completely
Signed “Data Use Agreement”
Notarized “Certificate of Acknowledgment”
Signed
“Information Privacy and Security
Requirements”
Signed “Statement of Intended Use” on organization letterhead
Appropriate Data dictionary(s) attached and all desired variables explained (custom
files only) for each year requested.
Note: If requesting confidential fields from certificate, VSAC approval is required
VS 144 (3/18)
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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION FOR
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR GOVERNMENT AGENCY USE
Application Checklist
“Application for California’s Birth and Death Data Files for Government Agency Use”
filled out completely
Signed “Data Use Agreement”
Notarized “Certificate of Acknowledgment”
Signed
“Information Privacy and Security
Requirements”
Signed “Statement of Intended Use” on organization letterhead
Appropriate Data dictionary(s) attached and all desired variables explained (custom
files only) for each year requested.
Note: If requesting confidential fields from certificate, VSAC approval is required
VS 144 (3/18)
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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION FOR
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR GOVERNMENT AGENCY USE
Application Instructions
Government agencies may apply to receive custom data files from the California Comprehensive Death
data file. This application should be used by government agencies requesting birth and death public use,
and multiple causes of death data to fulfill business needs (administrative uses, meeting statutory
reporting requirements, providing required information to funding agencies, etc.). According to statute
102430 of the Health and Safety Code, all requests for birth, birth cohort, and fetal death must be
submitted using the research application.
Requests from government agencies for vital records data for official government business require the
approval of the State Registrar. On the agency’s letterhead, please provide a statement of the intended
use for the requested data and attach it to this application. The statement must include a description of
how the data will be used, including any data products to be derived from the vital records data that the
requesting agency plans to distribute internally or externally. If the data will be used to prepare tables for
public release, the statement of intended use must include a description of how the agency will ensure
that small cell sizes are suppressed. The data files released pursuant to this application may not be
used for fraudulent purposes and may only be used under the terms and conditions specified in this
application.
The California Birth and Death Public Use Data Files, Death Data Files, and MCOD Files are available
on CD-ROM. Payment is required before data files can be released, once your application is approved,
CDPH will provide a cost for creation of the custom data files. If an invoice is needed in order to process
a check, please contact the Health Information and Research Section (HIRS) at the telephone number or
e-mail listed above. Make all checks or money orders payable to California Department of Public Health.
CDPH cannot accept credit cards or send data files via a purchase order.
Mail, fax, or email the completed and signed application:
California Department of Public Health
Health Information and Research Section
Attn: Data Request Desk, MS 5102
P.O. Box 997410
Sacramento, CA 95899-7410
Phone: (916) 552-8095
Fax: (916) 650-6889
E-Mail:
HIRS@cdph.ca.gov
Private courier deliveries are not accepted using the P.O. Box above. If you would like to overnight the
completed application, please call or email for the physical location.
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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION FOR
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR GOVERNMENT AGENCY USE
Name:
Date:
Title:
Organization:
Street Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Data Request for Future Years
Future years of data are limited to the year of data currently available plus three additional future
years. As an example, if the 2016 CCMDF Death data is the latest year available, applicants may
only request this data through 2019 (current year, plus three additional future years).
Data File(s)
Please Indicate the
Frequency
Year(s)
W = Weekly
M = Monthly
Requested
Q = Quarterly
A = Annual
PUBLIC USE
Year(s) Requested:
BIRTH
to
W
M
Q
A
(1905-2017 available)
DEATH
to
W
M
Q
A
(1905-2017 available)
ANTI-FRAUD
Year(s) Requested:
BIRTH
to
W
M
Q
A
(1905-2017 available)
DEATH
to
W
M
Q
A
(1905-2017 available)
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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION FOR
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR GOVERNMENT AGENCY USE
Death Data is available in various formats. See
DEATH COMPARISON CHART
for California Death
Data sources available to be requested and utilized. Effective 2016, the Multiple Causes of Death
(MCOD) variables are available in the California Comprehensive Death File (CCDF) and the
California Comprehensive Master Death File (CCMDF): sequence numbers 201-240.
Indicate the source and the year(s) requested below.
Data File(s)
Please Indicate the
Frequency
Year(s)
W = Weekly
M = Monthly
Requested
Q = Quarterly
A = Annual
DSMF
Year(s) Requested:
(1970-2013 available)
Annual Only
to
CCDF Dynamic
Year(s) Requested:
(2005-2017 available)
W
M
Q
A
to
CCDF Static
Year(s) Requested:
(2005-2016 available)
Annual Only
to
CCMDF
Year(s) Requested:
(2014-2016 available)
Annual Only
to
MULTIPLE CAUSE OF
Year(s) Requested:
DEATH
Annual Only
to
(1970-2016 available)
For ALL BIRTH, BIRTH COHORT, and FETAL DEATH Data Requests
Agency Must Submit Research Use Application**
** Per H&SC 102430, all requests for birth, birth cohort, and fetal death must be reviewed by CPHS and VSAC and approved by the State Registrar for release.
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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION FOR
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR GOVERNMENT AGENCY USE
Data Delivery
CDPH will create custom data files based on the data fields selected in the appropriate data
dictionary(s). Indicate which fields to include on the custom data file by placing a “yes” in the
appropriate column and providing a reason for including this field in the data file.
Applicants/entities requesting regular delivery of weekly, monthly, or quarterly data files must enter
into a contract with CDPH. Please indicate how frequently the data will be delivered, and you will be
contacted by CHSI staff to discuss procedures.
Statement of Intended Use
Attach a signed statement of intended use on your organization’s letterhead describing how you
propose to use the requested data, including the years and data type. If the data are to be linked,
please clearly explain the purpose of the data linkage, who will be conducting the data linkage and
what datasets the vital records data will be linked to.
Data Access
Required only if requesting Death or MCOD files: List the names of all persons who will have
access to the requested data files and explain their affiliation to the sponsoring agency
(applicant, contractors, other).
Name
Affiliation
Address (if different than the Applicant)
Disclaimer
Data files may not be accurate or complete due to a variety of circumstances, including
amendments to the legal records that may have been filed after the production of the data files.
Data files are not legal records and should not be used as substitutes for the legal records from
which they were derived.
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Download Form VS 144 Application for California's Birth and Death Data Files for Government Agency Use - California

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