DATA LINKAGE BRANCH
AMENDMENT REQUEST FORM
All amendment requests should first be discussed with a member of the Data Services team
(dataservices@health.wa.gov.au) so advice can be provided on what action is required.
Please note that amendments and/or updates may require approval from DOHWA HREC
and/or institutional ethics committees. Extra costs may also apply.
If you require an amendment or data update to a project that was approved more than one
year ago, please be aware you may be required to submit a new Application for Data form
with all attachments.
Please note that ongoing, regular updates of data are only available if these were specified in
the original application. Extraction updates should not request data past the current
year.
PROJECT
NUMBER
PROJECT TITLE
PRINCIPAL INVESTIGATOR
CONTACT INVESTIGATOR
AMENDMENT REQUEST
Please provide a brief description of the amendment you require
PROJECT CHANGES
Mark all changes that are applicable, then complete the relevant sections below. Double click on the box and
select ‘Checked’ as default value.
1.
Linkage update
2.
Extraction update
3.
Addition of variables from previously approved datasets
4.
Extension of years of data from previously approved datasets
5.
Addition of new datasets
6.
Location
7.
Other (please specify below)
1.
LINKAGE UPDATE
This section should only be completed where external datasets are to be linked to core DOHWA datasets.
Provide details on the linkage update you require. Please attach the Linkage Form and if you require a data
extraction fill out Section 5 and attach the Extraction Form and variable lists.
2.
EXTRACTION UPDATE
Select which datasets you wish to access. Please attach Extraction Form and relevant variable lists.
Emergency Department Data Collection
Birth Registrations
Hospital Morbidity Data Collection
Electoral Roll
Mental Health Information System
Midwives Notification System
WA Cancer Registry
Mortality
Other (please specify below)
3.
ADDITION OF VARIABLES
List the dataset/s and extra variables you require. Please attach relevant variable list/s.
4.
EXTENSION OF YEARS
List the dataset/s and extra years you require. Please attach relevant variable list/s. If you require a new
extract please also complete Section 4.
5.
ADDITION OF NEW DATASETS
Select which datasets you wish to add.
Emergency Department Data Collection
Hospital Morbidity Data Collection
Mental Health Information System
WA Cancer Registry
Other (please specify below)
6.
Birth Registrations
Electoral Roll
Midwives Notification System
Mortality
LOCATION
Provide the new location/s of the project and a brief explanation of why the location has changed. Please
note that a new security plan and retention and disposal plan will be required.
6.
OTHER AMENDMENT
Provide details on the amendment required.
7.
DECLARATION
I DECLARE that:

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The project will continue to be conducted in accordance with the original application, and/or the updated
protocol, of which DOHWA HREC and/or institutional Ethics Committee have been advised
Any further change in protocol, timeline or personnel will be notified in writing to the Data Linkage Branch
(and DOHWA HREC if applicable) and a Confidentiality Agreement (non-public sector researchers) or a
Confidentiality Acknowledgment (public sector workers) will be provided for each new member of the
research team.
Any Department of Health data accessed for the purposes of this project will not be used for any other
project or released to any third party not specified in the original or amended application.
I understand that approval for continued access to confidential data from the Department of Health
datasets will be granted by DOHWA HREC subject to and conditional upon provision of:

An Annual Progress Report (for projects expected to continue longer than 1 year)

A Final Report and a copy of any published material based on this research or at least

Evidence of publication of outcomes.
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Any further information as requested by DOHWA HREC
Information will be stored securely, and the confidentiality of all data collected from or about participants
will be maintained
The information that I have supplied is true and correct in every particular.
SIGNATURE OF PRINCIPAL INVESTIGATOR
DATE
SIGNATURE OF CONTACT RESEARCHER
DATE