NICCase Manager:
Data Approvals Owner/Information Asset Owner:
Data Access Request Service (DARS) Application
1. Applicant Details
Request Title:
Name of Applicant Organisation:
Contact name and details:
HSCIC Framework Contract reference:
Name(s) of Data Controller(s)
(if different from applicant):
Name(s) of Data Processor(s)
(if different from applicant):
Information Asset Owner(s) (IAO):
Organisation Type
CQC-Registered Health or/and Social Care Provider
Local Authority
Other Health and Social Care System Public Body
Government Agency Outside of Health and Adult Social Care
Academic Institution
Independent Sector Organisation
Individual Citizen(s)
Commercial
Other
England
/ Wales
Location of:
UK
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Processing
Storage
Territory of use
EEA
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Other
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Please specify:
Address (including name of organisation)
If “Other”, please specify:
2. Summary
Reason for DAAG
Referral
Agreement
Type
☐ New
☐ Extension
☐ Renewal
☐ Amendment
☐ Recommendation to Disseminate Data
☐ Recommendation to Extend or Amend Existing Agreement
☐ Advice
Explanation
A new agreement
The same data, for longer.
Additional data of the same type, possibly for longer.
A change to an existing agreement such as the addition of other datasets, a
changed reuse purpose or change to the receiving organisation(s) or legal
basis
Previous
Agreement Ref:
Not applicable
Summary
(this may be
published
within the
DAAG
minutes)
DARS Application template v4.7 20/11/2015
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NICCase Manager:
Data Approvals Owner/Information Asset Owner:
Level of data requested from HSCIC (check all that apply)
☐Tabulations (obeying Small Number Policy, non-sensitive, anonymised)
☐Tabulations (others)
☐Aggregated (no small number suppression)
☐Aggregated (with small number suppression)
☐Pseudonymised, non-sensitive
☐Pseudonymised, sensitive
☐Identifiable, non-sensitive
☐Identifiable, sensitive
☐ONS data
3. Datasets Held/Requested
Add rows to tables as necessary.
3.1 Data already held for this project/purpose (not applicable if a new application)
Dataset(s)
“Level” of data
Legal Basis for
Dissemination
Dataset
period
Data minimisation efforts
(cohort, geographical area,
etc.)
“Level” of data
Legal Basis for
Dissemination
Dataset
period
Data minimisation efforts
(cohort, geographical area,
etc.)
3.2 Data requested
Dataset(s)
Notes:
If any of the datasets involve ONS data, please complete Section 8 at the end of this document.
Any other data sources involved in this application must be fully described in section 5.
4. Period and Funding
Planned Data Retention Period:
(data to be deleted at this point)
Reason for this period:
DARS Application template v4.7 20/11/2015
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NICCase Manager:
Data Approvals Owner/Information Asset Owner:
Proposed Agreement end date:
4.1 EU/International funding
Other projects or activities, directly related to this application, which have obtained EU/International financial support in
the last five years:
Details
Evidence
Awarding Institution
EU/International
programme
Reference and title of
project/activity
Year of submission/award
Applicant or Partner
4.2 Other relevant (public/private) funding
Details
Evidence
5. Purpose/Methods/Outputs
Purpose
The Data Recipient agrees to process the Data only for the following purposes agreed with the
HSCIC.
Note: this
information
Objective for processing:
may be
published by
the HSCIC
Processing activities:
Specific outputs expected, including target date:
Expected measurable benefits to health and/or social care including target date:
Is the purpose of this
application in anyway
commercial?
YES / NO, if yes, please explain.-
DARS Application template v4.7 20/11/2015
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NICCase Manager:
Data Approvals Owner/Information Asset Owner:
6. Approval Considerations
Materials Reviewed
Version and Date
of Document
Date of
Approval
Expiry /
Review
Date
Comments
Protocol
Ethics Review
Consent form
Patient information
Patient/GP letters
Section 251 support
ONS
Details of users should be entered in
section 8.
Fair processing
ICO guidance on privacy notices:
https://ico.org.uk/for_organisation
s/data_protection/topic_guides/pr
ivacy_notices
7. Security Assurance
Complete this section for each organisation involved.
Security
Assurance
IG Toolkit
ISO 27001
Other
Version and Date Complete
Comments
Org code and score:
Please supply the certificate
DPA Registration
Expiry date
Activity recorded (ICO application forms list Sector and reasons
for processing data)
Org code and name:
8. ONS Users
Only complete if ONS data is requested
Name
Position
Organisation
Legal basis
(if different from applicant)
(s42 (4) SRSA 2007, Consent,
AR+MRP, Other)
DARS Application template v4.7 20/11/2015
Expiry /
Review Date
(if applicable)
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NICCase Manager:
Data Approvals Owner/Information Asset Owner:
9. Specification and Service Requested
Standard
Extract
Dataset(s)
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Personal Demographics Service (PDS)
Hospital Episode Statistics (HES): Inpatient
HES: Outpatient
HES: A+E
HES: Critical Care
Mental Health Minimum Data Set (MHMDS)
SUS Payment By Results (PBR)
Diagnostic Imaging Dataset (DID)
Patient Reporting Outcome Measures (PROMS)
Scottish NHS / Registration
Mortality
Birth
Cancer Registration
Linked datasets, please specify:
Other, please specify:
Frequency
One-off
Periodic - Monthly
Periodic - Quarterly
Periodic - Annually
Ad hoc – irregular dissemination
Continuous – user access to HSCIC system
Bespoke
Extract
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Tabulation
Linkage
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Patient
Status and
Tracking
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Number of Disseminations Expected
Not applicable
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Not applicable
Not applicable
10. HSCIC Governance Path (for HSCIC use only)
IAO
☐Not required
☐Required
☐Approved
☐Unable to approve
Director
☐Not required
☐Required
☐Approved
☐Unable to approve
DARS Application template v4.7 20/11/2015
DAAG
☐Not required
☐Required
☐Recommended for approval
☐Unable to recommend for approval
SIRO
☐Not required
☐Required
☐Approved
☐Unable to approve
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