Form VS142 "Application to Purchase California's Birth and Death Data Files for Local Health Departments" - California

What Is Form VS142?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form VS142 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form VS142 "Application to Purchase California's Birth and Death Data Files for Local Health Departments" - California

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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 LOCAL HEALTH DEPARTMENTS
Application Checklist
“Application for California’s birth and death data Files for Local Health
Departments (LHDs)” filled out completely and signed.
Signed “Statement of Intended Use” on LHD letterhead (only when
requesting data outside of your jurisdiction).
Signed
“Information Practices and Security Requirements
Form”
• Not needed if your county has executed a data use agreement and
received Vital Records Business Intelligence System (VRBIS) training.
Contact Health and
In formation Research Section at
HIRS@cdph.ca.gov
if you need
assistance in identifying an authorized user for your LHD.
• If your county has access to the VRBIS, Death data may be downloaded
directly.
VS 142 (1/19)
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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 LOCAL HEALTH DEPARTMENTS
Application Checklist
“Application for California’s birth and death data Files for Local Health
Departments (LHDs)” filled out completely and signed.
Signed “Statement of Intended Use” on LHD letterhead (only when
requesting data outside of your jurisdiction).
Signed
“Information Practices and Security Requirements
Form”
• Not needed if your county has executed a data use agreement and
received Vital Records Business Intelligence System (VRBIS) training.
Contact Health and
In formation Research Section at
HIRS@cdph.ca.gov
if you need
assistance in identifying an authorized user for your LHD.
• If your county has access to the VRBIS, Death data may be downloaded
directly.
VS 142 (1/19)
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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 LOCAL HEALTH DEPARTMENTS
Application Instructions
The California Department of Public Health (CDPH) makes birth and fetal death data available on CD-
ROM pursuant to Health and Safety Code (HSC) Section 102230(c).
Local health departments (LHD) may obtain one copy of their own comprehensive birth, death, fetal
death data files and the multiple cause of death data file for the most recent year at no charge.
Subsequent requests are subject to cost recovery pursuant to HSC Section 102230. Data files are
provided in the format that they were created. Data elements and file formats differ depending on the
requested year.
Death data are available through the Vital Records Business Intelligence System (VRBIS). If your LHD
cannot access VRBIS and would like to receive death data, please complete and sign this application. If
,
your LHD needs an executed data use agreement
VRBIS training or a password reset, please contact
the Health Information and Research Section (HIRS) at
HIRS@cdph.ca.gov
for further information.
If requesting weekly, monthly, or quarterly file(s), CDPH will provide a cost estimate (if applicable) and
generate an invoice prior to data file completion. Payment must be received prior to the release of data.
Credit card payment is not accepted.
Mail, fax, or email the completed and signed application to:
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 and payment, 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
LOCAL HEALTH DEPARTMENTS
Name:
Date:
Title:
LHD:
Street Address:
City:
State:
Zip Code:
Phone:
Fax:
Email:
Data File(s)
Please Indicate the
\
Year(s)
Requested
BIRTH (1960-2017 available)
Year(s) Requested:
to
BIRTH COHORT (1980-2016 available)*
Year(s) Requested:
to
This file includes all live births and the infants who
died in the first year of life (linked to the birth).
DEATH: County deaths only (1970-2017)*
Year(s) Requested:
to
DEATH : County and out-of-state deaths
Year(s) Requested:
to
(1970-2017)
DEATH: Out-of-State deaths only (1970-2017)
Year(s) Requested:
to
To request statewide death data, submit a
“Government
Agency
Use” application
FETAL DEATH (1978-2017 available) **
Year(s) Requested:
to
MULTIPLE CAUSES OF DEATH (MCOD)
Year(s) Requested:
to
(1970-2016 available)
* Includes county reallocates for jurisdiction, but not out of state reallocates. A county reallocate is an
occurrence in which a birth, death, or fetal death occurred outside of the requested county, but the
individual is a resident of the county. **Fetal Death currently does not include out-of-state data.
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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
LOCAL HEALTH DEPARTMENTS
Data Delivery
Local health departments (LHD) may obtain one copy of their own comprehensive birth, death, fetal
death, and the multiple cause of death data files for the most recent at no charge. Subsequent
requests are subject to cost recovery pursuant to HSC Section 102230.
Data Access
List the names and addresses of all persons who will have access to the requested data files
and explain their affiliation to the LHD. Please include a separate attachment if additional space is
needed.
Name
Affiliation
Address (if different than the applicant’s address)
Information Privacy and Security Requirements
Death data are available through the Vital Records Business Intelligence System (VRBIS). If your
LHD has received VRBIS training within the past 3 years, you may download directly from VRBIS
with an executed data use agreement. Out of state death data is currently not available in VRBIS.
For access to VRBIS, a signed copy of the
Information Privacy and Security Requirements
document is required prior to data release.
If your LHD cannot access VRBIS and would like to receive death data, please complete and sign
this application. If your LHD needs VRBIS training or a password reset, please contact the Health
Information and Research Section (HIRS) at
HIRS@cdph.ca.gov
for further information.
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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State of California - Health and Human Services Agency
California Department of Public Health
Center for Health Statistics and Informatics
APPLICATION TO PURCHASE
CALIFORNIA’S BIRTH AND DEATH DATA FILES
FOR LOCAL HEALTH DEPARTMENTS
Data Use Agreement
I, the undersigned, on behalf of the Local Health Department or Local Registrar’s office represented
in this application, agree to the following:
1. I agree not to release or allow public access to the birth, death, or fetal death data files, and I
agree not to post the data on the Internet.
2. I agree to use the birth, death, or fetal death data files only for the purposes specified in this
application.
3. I will not sell, assign, or otherwise transfer the birth, death, or fetal death data files, or any
portion of the data files, and I will not release names or other personal identifiers from the data
files.
4. I will not use the birth, death, or fetal death data files for fraudulent purposes.
5. I understand that the release of confidential birth data with personal identifiers or the linkage of
non-confidential data with other files so as to identify an individual’s confidential data without
prior approval may be punishable by a fine of $500 or six months in jail (HSC Section 102475).
6. I further agree to acknowledge the CDPH as the original source of the data for any material
derived from these vital statistic files.
If reallocate data is requested, I further agree to the following:
1. I may use the data for statistical analysis as long as no personally identifiable information is
released.
2. I may use the data for public health surveillance, public health program evaluation, or
administrative use consistent with the statement of intended use provided on page 1.
3. If the intended use of the data is for health related research, the request for data must be
submitted to the Vital Statistics Advisory Committee and the Committee for the Protection
Human Subjects. In addition, I agree that data received for health related research is deemed
confidential and any personally identifiable data shall not be released.
4. The data will be stored on a secure network and must be returned or destroyed when the
project described in the statement of intended use has been completed.
5. Any other release, re-release, or use of the vital records data requires the written permission of
the originating state or territory.
Applicant Signature:
Date:
Printed Name:
Title:
Local Health Department Name:
Local Registrar or Local Health Officer
Signature:
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