laboratory information request intake form

Laboratory Information Request Intake Form

Section I: Requestor & Sponsor Information

Affiliation should be for the purpose of the data use. DATA ACCESS AND USE FOR HEALTH SYSTEM IMPROVEMENT PURPOSES

(SECONDARY USE) Policy 1178 (ahsnet.ca)

Choose an item.

First Name: Click or tap here to enter text. Last Name: Click or tap here to enter text.

Telephone: Click or tap here to enter text. Email: Click or tap here to enter text.

Requestor Affiliation*: Choose an item.

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Sponsor First Name: Click or tap here to enter text. Sponsor Last Name: Click or tap here to enter text.

Telephone: Click or tap here to enter text. Email: Click or tap here to enter text.

Requestor Affiliation*: Choose an item.

Section II: Basic Request Information

Intake Type:

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Project: Sequential requests for information that lead to a certain outcome. Requests are often

dependent on each other. There is a defined start and end date with measurements of success.

Request for Laboratory Data: Data requests that support business needs and are usually standalone

requests or regular reporting requests.

Project/Request Title:

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Previous Request No. (if

applicable):

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Request Type:

Choose an item.

APL Business Plan Initiative: Support evaluation of Business Plan

Operational: Decision making, investigative, performance, safety or compliance reporting

Quality Improvement: Examining existing services and patient outcomes to determing how services

can be improved for the future – HIA Guidelines and Practices

Research: Academic, applied or scientific research that necessitates the use of individually

identifying health information – HIA

Other (Please specify if “Other” selected above): Click or tap here to enter text.

Please supply the following information for APL Business Plan Initiative requests:

APL Business Plan Initiative Name: Click or tap here to enter text.

APL Business Plan No. (if available): Click or tap here to enter text.

Laboratory Information Request Intake Form

Data Type:

Select all that apply:

☐ Aggregate Information

☐ Identifiable Information

☐ Non-identifiable information

☐ Other

Other (Please specify if ‘other’ selected above): Click or tap here to enter text.

Aggregate Information: Non-identifiable health information about groups of individuals with

common characteristics

Identifiable Information: Individually identifying when used to describe health information, means

that the identity of the individual, who is the subject of the information, can be readily ascertained

from the information.

Non-identifiable Information: Identity of the individual who is the subject of the information

cannot be readily ascertained from the information.

(Source: HIA Guidelines and Practices)

Required Supporting

Documentation:

Select all that apply:

☐ APL Business Plan

☐ Quality Improvement

☐ Research Request

APL Business Plan:

• Business Plan Placemat

• ARECCI Screening Tool Result is not necessary for Business Plan request

Quality Improvement:

• ARECCI Screening Result

Research Request:

• Protocol

• Ethics Approval

• Ethics Application

Please attach any supporting documentation available at this time upon submission of request

form.

Section III: Operations, Research, QI Request Assessment, and Other

*If Request Type is APL Business Plan Initiative, please skip ahead to Section IV.

Business Justification:

Please provide a brief summary as to why it is important for this request to proceed at this time.

Please also explain how this request will improve laboratory medicine/patient care in Alberta.

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Knowledge Translation

Plan:

Outline your knowledge translation plan for the findings from your request. (Who will the findings

be shared with? Publication and/or Communication Plan? Implementation strategy?)

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Funding:

How is the project funded? (if applicable)

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Laboratory Information Request Intake Form

Engaged Personnel:

Who have you engaged in Alberta Precision Laboratories/Alberta Health Services to ensure

relevance and applicability of this work?

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Section IV: Request Details

Identifying Information:

Please specify any/all personal identifying data and demographic information

☐ Patient Health Number (PHN)

☐ Medical Record Number (MRN)

☐ Patient Name

☐ Date of Birth

☐ Age

☐ Gender

☐ Postal Code

☐ Physician Name/Number

☐ Accession Number

☐ Other (Please specify): Click or tap here to enter text.

Laboratory Data Type:

Select all that apply:

☐ Testing volumes by performing site

☐ Laboratory collections volumes by collection site

☐ Test Results (Numerical, Normal/Abnormal, Comments etc.)

☐ Quality Control data

☐ Laboratory Workload

☐ Turnaround Times

☐ Other (Please specify): Click or tap here to enter text.

List any and all Tests of Interest:

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Zone:

Select all that apply:

☐ North

☐ Edmonton

☐ Central

☐ Calgary

☐ South

☐ Provincial

Laboratory Discipline:

Select all that apply:

☐ Anatomic Pathology

☐ Biochemistry

☐ Genetics, Genomics, Molecular Pathology

☐ Hematology

☐ Histocompatibility

Laboratory Information Request Intake Form

☐ Microbiology

☐ Point of Care Testing (POCT)

☐ Pre-Analytics

☐ Transfusion Medicine

☐ Unknown

Data Delivery Format:

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Data Release Frequency:

Please note that requests are only valid for 12 months. Annual requests require new submissions.

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Data Delivery Method:

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Data Storage:

Where will the data be stored?

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Other (please specify): Click or tap here to enter text.

Data Matching:

Will data be linked, matched or combined with records from other sources?

Data matching is the creation of individually identifying health information by combining

individually identifying or non-identifying health information or other information from 2 or more

electronic databases, without the consent of the individuals who are the subjects of the

information.

Data linkage is computerized use of health information and other personal data from a variety of

sources, to merge and compare files on identifiable individuals or categories of individuals. This

linkage or profiling creates a new body of health information

(Source: HIA Guidelines and Practices)

Check if yes: ☐

If yes, please explain:

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Time Frame of Interest:

Start of date range:

Click or tap to enter a date.

End of date range:

Click or tap to enter a date.

Date Required:

Please be aware that the requests are reviewed by the Clinical Informatics Committee on the

second and fourth Friday of every month. Expected turnaround time is 1-6 months subject to the

volume of requests received. Urgent requests can be escalated to DecisionSupport@aplabs.ca

Click or tap to enter a date.

Laboratory Information Request Intake Form

Section V: Submission Information/ User Agreement

User Agreement

Alberta Precision Laboratories (APL) has a legal and ethical responsibility to protect, manage and secure information within its

custody or under its control to maintain the confidence of patients and stakeholders. The User Agreement describes how you,

the user, must manage data.

You have been approved for the release of data outlined as part of your duties and responsibilities. As part of your

responsibility, you must know and follow the conditions for use and disclosure of all data you have access to.

It is required that you treat identifiable health and other information as confidential. Identifiable health information is governed

by both provincial legislation and APL policies.

You must sign this Agreement before you will be granted access to the data outline in this agreement.

Appropriate Use and Disclosure of Data

1. I understand and acknowledge that I am accountable to use and disclose data only in accordance with this agreement

as well as the policies and legislation that govern this data.

2. I shall only access, use and/or disclose the minimum data necessary with the highest degree of anonymity possible for

the purpose of fulfilling my job duties and responsibilities.

3. I shall not access my own information, or the information pertaining to a family member, friend, colleague, or anyone

who is not within the scope of my duties and responsibilities.

4. I understand and acknowledge that the access is for authorized secondary uses (e.g. Quality Improvement, research)

only and is not intended for direct patient care.

5. I shall not duplicate data without consent of the APL Repository Owner.

6. I understand and acknowledge that the data contains proprietary information and that I shall not redistribute this

information.

7. I understand and acknowledge that I may bring other data into my personal or subject schema; however, if I plan to

match non-APL data with APL data (and I am not conducting research), I will be required to first complete a Privacy

Impact Assessment or a schedule to the existing repository Privacy Impact Assessment, as required under the Health

Information Act, section 70.

8. I shall not disclose information to a third party without the expressed written consent of the Repository Owner prior to

the disclosure.

9. I shall dispose of any data I access from APL, regardless of form, in a secure manner that renders the information

unreadable.

10. I shall use reasonable means to ensure that while I am accessing APL information it will not be viewed or obtained by

unauthorized people (e.g. secure my computer, be discreet when viewing data, not share my passwords).

11. I have reviewed, understand, and acknowledge the APL Data Access and Use for Health System Improvement Purposes

(Secondary Use) Policy.

Confidentiality Provisions

1. I shall take reasonable actions to keep all information private and confidential, and prevent the unauthorized

collection, use and/or disclosure of all information that I come into contact with.

2. I accept that the obligation to keep APL information confidential continues even after I leave my organization or if my

current role changes, and either I or my manager will notify DecisionSupport@aplabs.ca with my end date should

either event occur.

3. If I become aware of a violation of any provisions referenced above or a potential or actual breach of confidentiality or

privacy, I will notify my Supervisor immediately. I will also notify DecisionSupport@aplabs.ca as soon as possible.

Laboratory Information Request Intake Form

Audit and Sanctions

1. I understand and acknowledge that user system performance will be monitored.

2. I understand and acknowledge that regular audits are conducted and reviewed for appropriate access and use.

3. I understand that the Decision Support Team may revoke or restrict access to any Alberta Health Services and/or

Alberta Precision Laboratories data without notification.

Acknowledgement/ Publication

*Suggested acknowledgement:

Alberta Precision Laboratories Laboratory Information Systems. Decision Support, Alberta Precision Laboratories, [year].

If the data provided are used in publications, presentations, or posters, please inform DecisionSupport@aplabs.ca as soon as

possible.

I acknowledge that I have read the provisions referenced above and understand there may be consequences for a violation of

those provisions and/or this Agreement.

☐ I have read and understand the provisions referenced above and hereby agree to the terms as stated.

Please return this form and supporting documents to [email protected] upon completion with

subject line indicating RFD submission <your name>.