Virginia Health Information (VHI) Data Request Form

NOTE: Request should be submitted at least 3 weeks prior to the expected deadline.

Date of Request Date of Request * / MM / DD YYYY
Deadline Date Deadline Date * / MM / DD YYYY
Principle Investigator Information
Name Name * First Last
Title *
Type *
Department *
ODU Email *
Phone Phone * - ### - ### ####
Project Information
Project Title *
Have you reviewed the variables available at the VHI website (https://www.vhi.org/) to make sure that the variables you requested can be obtained? *

Have you reviewed the variables available at the VHI website (https://www.vhi.org/) to make sure that the variables you requested can be obtained? Yes No
What is your main research question/purpose of the study? *
What additional research questions, if any, do you have? *
What is your study population? Please include all inclusion/exclusion criteria that should be
considered, such as age, sex, or race of the patient, diagnosis codes, procedure codes, etc. *
Briefly describe your planned analyses. *
Which variables are you requesting? Please review the VHI data dictionary for a full *
What year(s) are you requesting? VHI data goes back to 2008 and typically has a 2 year delay
before it is available. *
Please describe your planned dissemination, e.g., conference poster or talk, manuscript, etc. *
Do you plan to link VHI data with other datasets? If so, please describe in detail. *
Have previous years of data been provided for this project in the past? *

Have previous years of data been provided for this project in the past? Yes No
If yes, please describe:
Who will have access to the raw datasets and what are their roles in this study? *
Add any additional information that may assist this review:
*

I understand I am permitted to use the data for this particular research study only. I understand that data will not be shared. For any publications and presentations, I agree to acknowledge the Macon and Joan Brock Virginia Health Sciences Brock Institute for Community and Global Health and the Macon and Joan Brock Virginia Health Sciences Research & Infrastructure Service Enterprise (RISE). I understand and agree to abide by all the terms and restrictions described regarding the use of the Virginia Health Information (VHI) patient level data.
Virginia Health Information (VHI) Data Use Agreement

The Macon and Joan Brock Virginia Health Sciences/The Brock Institute has purchased a license to use patient-level data from Virginia Health Information (VHI). By submitting this request to access data from the VHI database, you acknowledge and agree to the following:

1. All VHI data may only be used for the purpose stated above or to generate documentation necessary to properly conduct such purpose. If the purpose should change, additional permission must be sought from the Brock Institute.

2. All VHI data must be handled in a confidential manner, and attempts, by commission or omission, to identify, disclose, discuss, release, or provide access to information on specific individual patients is prohibited.

3. No VHI data, or any information or documentation generated from such data, may be licensed, rented, leased, distributed, transferred, or otherwise shared with any third party without permission from the Brock Institute.

4. VHI data may not be used for research purposes without Virginia Health Sciences IRB review.

5. If direct access to the VHI database is granted:

a. Access privileges and/or login credentials to the VHI system may not be shared with any other person.

b. Transactions on the VHI database may be logged and are subject to audit.

c. The Brock Institute reserves the right to revoke a user's access privileges at any time.

6. The following statements must be included on any report, publication, information, documentation, or other works created using VHI data:

In conjunction with M. Foscue Brock Institute for Community and Global Health at Virginia Health Sciences.

VHI has provided non-confidential patient-level information used in this file, report, publication, or database which it has compiled in accordance with Virginia Law but which it has no authority to independently verify. By using this file, report, publication, or database, the user agrees to assume all risks that may be associated with or arise from the use of inaccurate data. VHI cannot and does not represent that the use of VHI's data was appropriate for this file, report, publication, or database or endorse or support any conclusions or inferences that may be drawn from the use of VHI's data.

7. Violation of any terms stated above will result in future access to VHI being revoked and may be subject to disciplinary action in accordance with Virginia Health Sciences policies.
I have read, understand, and agree to comply with the Virginia Health Information (VHI) Data Use Agreement. *

I have read, understand, and agree to comply with the Virginia Health Information (VHI) Data Use Agreement. I agree

Virginia Health Information (VHI) Data Request Form

Virginia Health Information (VHI) Data Request Form

Principle Investigator Information

Project Information

Virginia Health Information (VHI) Data Use Agreement