Form HLTH5509 "Health Data Request Amendment Application" - British Columbia, Canada

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Health Data Request
AMENDMENT APPLICATION
Date of Submission
Project Title
Project Number
Principal Investigator/Applicant
Organization
Address
Phone
Email
IF THE PROJECT IS A RESEARCH PROJECT, PLEASE PROVIDE THE FOLLOWING INFORMATION AS WELL
Current Ethics Approval
Review Body
Certificate Number
Expiry Date
Current Funding Source
Funding Expiry Date
Data Approved with Original Request (list all approved data files and date range)
Data Storage
List Team Members and Data Access
Amendment Request
Cohort update/change to cohort
Other, please describe
Addition of year(s) of data (extract)
Addition of data file(s) and/or data field(s)
Addition of external data linkage(s)
Data retention extension
Detailed Description of Amendment
Rationale
Expected End Date of Project (Year, month)
HLTH 5509 2017/05/03
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Health Data Request
AMENDMENT APPLICATION
Date of Submission
Project Title
Project Number
Principal Investigator/Applicant
Organization
Address
Phone
Email
IF THE PROJECT IS A RESEARCH PROJECT, PLEASE PROVIDE THE FOLLOWING INFORMATION AS WELL
Current Ethics Approval
Review Body
Certificate Number
Expiry Date
Current Funding Source
Funding Expiry Date
Data Approved with Original Request (list all approved data files and date range)
Data Storage
List Team Members and Data Access
Amendment Request
Cohort update/change to cohort
Other, please describe
Addition of year(s) of data (extract)
Addition of data file(s) and/or data field(s)
Addition of external data linkage(s)
Data retention extension
Detailed Description of Amendment
Rationale
Expected End Date of Project (Year, month)
HLTH 5509 2017/05/03
PRINT
CLEAR FORM