REQUEST FOR INFORMATION FORM
Declaration by Requester:
By signing below, I certify that all information provided herein is accurate and complete. If any of the information provided
requires updating or has changed for any reason, I will immediately report the new information in writing to eHealth
Saskatchewan. I agree to abide by all applicable laws, regulations and international guidelines concerning health information
data sharing and disclosure. Furthermore, I agree to abide by the Conditions of Release and Information Use which are attached
to this form and will accompany the information released by eHealth (the Information).
Requester Details: (All Fields Mandatory)
Requester's Full Name: Organization:
Address: Work Phone #: ext:
City: Working Title:
Province: Postal Code: Email:
Details of Requested Information:
You will be contacted within 5 business days of receipt of the request by a member of the Information & Analytics
Services Department. If your request is of an urgent nature please email [email protected].
Type of Request (Check One):
New Similar data previously requested. Details can be provided in Additional Information on page 2.
Frequency of Data Required:
Once
Time Period From: Time Period To:
Ongoing
Weekly
Bi-Weekly
Monthly (please specify 1st, 15th, or end of month)
Quarterly (please specify 1st quarter end date)
Annually (please specify year end date to be used)
Please Indicate Purpose of Data Use:
Clinical/Patient Use Hoshin Work, Program Planning/Analysis/Monitoring, and Research, Data Quality)
Please Indicate Type of Data Being Requested:
De-Identified - Distinguished fields that could identify a person have been removed (e.g. name, address, phone,
HSN)
Identifiable - Includes distinguishing fields that could identify a person (e.g. name, address, phone, HSN)
(Note: Access to this level of data is provided only to approved users)
Please Indicate How You Would Like Data Returned to You:
Excel Extract(SFTP) GIS MicroStrategy Reports SAS Other(ST)
June 2020
June 2020
What is the project/program name related to this request?
What is the question/problem you want to address by receiving the data requested?
Describe the data you are requesting? If known, include the source database(s) or the list of data elements.
(e.g. Name, Address, Gender, DOB)
How is the requested information being used? List all intended uses/purposes. Include who (if anyone) you
will share this data with? (e.g. 2nd recipient of the data)
Additional Information:
Authorization: By submitting this form you agree to all the Conditions of Release and Information Use on page 3.
Requester Signature: Date:
(Note: Written signature not required if submitted from an email address containing the Requester's name)
June 2020
Conditions of Release and Information Use
1. The Requester shall only use the Information released for the purpose(s) described in the
original Request for Information Form. Any proposed change(s) to the purpose/use of the
information requires the prior written authorization of eHealth Saskatchewan (eHealth).
2. The Requester may share the Information released by eHealth with other members within the
Requester's organization only on a need to know basis and only to support the intended purpose
and use identified on the Request for Information Form.
3. The Requester shall not release the Information released by eHealth to any third party individual or
corporation without the prior written authorization of eHealth.
4. The Requester will take all reasonable steps to maintain the confidentiality of the Information.
5. eHealth assumes no liability for decisions, assumptions, conclusions made using the released
Information.
6. Requesters are responsible for breaches of confidentiality. Breaches must be reported to the eHealth
Privacy and Access Unit, 1-855-347-5465 as soon as the Requester becomes aware of the breach.
7. The Requester shall not link the Information released by eHealth for the purpose of creating identifiable
personal or personal health information.
8. Any use or disclosure of the Information released by eHealth, other than outlined in the Request
for Information Form, constitutes a breach of the Conditions of Release and Information Use and
may be an offense under HIPA. Possible consequences of this offense could result in a monetary
penalty to the Requester and/or their organization.
9. Released Information must be securely stored and destroyed as per the Requester's organizational
policies.
June 2020
