NICOR DATA ACCESS APPLICATION FORM
NICOR REFERENCE
(office use only)

Please refer to NICOR data sharing policy (including charges for data extracts) before
completing this application
(www.ucl.ac.uk/nicor/dataforresearch).

All sections must be completed. Incomplete forms will be returned which will cause a
delay to the application being reviewed.

All applications require submission of a data flow diagram and a statistical analysis
plan.

For applications requiring HQIP approval (please refer to NICOR’s data application
process flow chart), please provide a copy of your organisation’s:
o
o
o
o

Deletion policy
Data and IT usage policy
Data protection and security policy
Confidentiality policy
All research applications must register with clinicaltrials.gov http://clinicaltrials.gov/
prior to a data extract being provided by NICOR
SECTION I:
NICOR APPLICATION
Project title:
PI (Title, forename, surname):
Date of submission:
Has this application been previously submitted and rejected? If
yes, please give details:
SECTION II:
NICOR DATASET
EXTRACTS
REQUESTED
(Please indicate all that
apply)
SECTION III:
LINKAGE OF NICOR
☐
☐
☐
☐
☐
☐
☐
National audit of Myocardial Ischaemia (MINAP)
National Audit of Heart Failure
National Audit of PCI
National Audit of Adult Cardiac Surgery
National Audit of Cardiac Rhythm Management
National Audit of Congenital Heart Disease
Transcatheter Aortic Valve Implantation registry
Does your project involve linking NICOR dataset(s) with another
database? Yes ☐
No ☐ (if no, go to next section)
Name external dataset(s) NICOR data to be linked with:
1
DATASET EXTRACT
TO ANOTHER
DATASET
a)
b)
c)
Name of Trusted Third Party (TTP) who will conduct linkage:
a) Organisation:
b) Contact details:
SECTION IV:
GOVERNANCE
Have you read, and will you be able to accept the terms and
conditions for the NICOR (and HQIP, where applicable) data sharing
agreement(s):
Yes ☐
No ☐
Please provide your organisations UK Information Commissioner’s
Office (ICO) registration number:
Type of work applying for data for (must comply with the Health
Research Authority definitions http://www.hra.nhs.uk/researchcommunity/before-you-apply/determine-whether-your-study-isresearch/):
Research: ☐
Audit: ☐
Service evaluation: ☐
Ethics (for research applications only, if linkage with external NICOR
dataset):
Ethics reference (please attach copy of approval letter):
R and D (for all types of application):
R and D reference (please attach copy of letter):
Confidentiality advisory group (CAG) (for applications requiring
identifiable patient information without patient consent. More information
can be found at http://www.hra.nhs.uk/resources/confidentiality-advisorygroup/):
CAG reference (please attach copy of approval letter):
Others (Please provide details of any other permissions gained and
relevant reference):
Clinicaltrials.gov registration (research applications only)
Clinicaltrials.gov reference:
SECTION V:
FUNDING
Do you have funding to conduct this work? Yes ☐
please state how you plan to fund this work)
No ☐ (if no,
2
Name of funding body:
Dates/duration of award:
Title of application:
Synopsis of application (max 100 words):
SECTION VI:
PRINCIPAL
INVESTIGATOR
Title, forename, surname:
Employing organisation:
Position in organisation:
Address of organisation:
Academic affiliation of PI:
Telephone:
Email:
Please attach PI CV to your application
Research team member 1
Title, forename, surname:
Research team member 2
Title, forename, surname:
Employing organisation:
Employing organisation:
Position in organisation:
Position in organisation:
Telephone:
Telephone:
Email:
Email:
Research team member 3
Title, forename, surname:
Research team member 4
Title, forename, surname:
Research team member 5
Title, forename, surname:
Employing organisation:
Employing organisation:
Employing organisation:
Position in organisation:
Position in organisation:
Position in organisation:
Telephone:
Telephone:
Telephone:
Email:
Email:
Email:
SECTION VII:
RESEARCH TEAM/
CO-INVESTIGATORS
Please list the main publications of each research team member
SECTION VIII:
involved in the project:
PUBLICATIONS OF
THE RESEARCH
TEAM (INCLUDING PI)
SECTION IX:
Summary (a brief summary of up to 200 words describing the aims of
the work)
3
RESEARCH PROJECT
Context (Where research is part of a larger programme, please give
details):
Project description (Full description of the purpose/s for which the data
are requested (maximum 4 A4 sides excluding references).
Please use the structure in the NICOR Statistical Analysis Protocol. This
applies for all data sharing applications, whether submitted a request for
data for research, audit or service evaluation work. The main categories
are:









Title
Abstract
Background/rationale for the proposal
Objectives
Study design (including data flow diagram for linkage studies)
Statistical methods (including statistical analysis plan)
Results
Limitations of the work
Dissemination (including planned scientific outputs and a patient
and public dissemination strategy)
Proposed project completion date:
SECTION X:
DATA REQUESTED
Please refer to the audit datasets, available on the NICOR website
Dataset items required (Please refer to the relevant dataset template
(appendix 1-7))
Dataset time period:
Geographical location (e.g. UK, England, Wales, etc.):
Cleaned dataset ☐ raw data ☐
Annual updates required: Yes ☐
SECTION XI:
DATA MANAGEMENT
No ☐
Please state how the data will be stored and accessed:
Please outline the period of retention:
Please describe the IT infrastructure and network used to access
and retrieve the data:
Confirm if any portable/mobile media will be used (for example,
laptop/ CD/disk to retain/access the data):
4
SECTION XII:
PATIENT AND PUBLIC
ENGAGEMENT
Please provide details of the involvement of patients and the public
in the design of this work.
Please provide details on the relevance of the results to patients
and the public
Please provide a lay summary of your work (max 250 words)
SECTION XIII:
CONFLICTS OF
INTEREST
Please provide details of any conflicts of interest (for example,
financial, consultancy and professional activities, clinical trials,
equity holdings, Executive and non-executive directorships) of the
PI or research team.
SECTION XIV:
SIGNATURES
PI (organisation requesting the data):
The Parties have signed to
acknowledge that this
Agreement shall apply to any
Data shared by HQIP further
to any Data Sharing Request
Form completed by the
Applicant.
Name:
NB: This agreement is not
valid until all there
organisation have agreed
and signed:
Signature:
Position:
Address:
Email:
Date of signature:
NICOR Audit clinical lead (approval that the clinical lead is happy with
the proposed use of data):
Name:
Position:
Signature:
Date of signature:
NICOR approving committee Chair:
Name:
Position:
5
Signature:
Date of signature:
HQIP
Name:
Position:
Email:
Signature:
Date of signature:
6