NPDS Member Data Request Form

National Poison Data System®

Member Data Request Form (DRF)
Which of the following describes your affiliation with America's Poison Centers?*

I am a Poison Center member or America's Poison Centers Clinical LeadershipI am not a Poison Center member, but a member Poison Center Director has agreed to sponsor and collaborate on this requestI am not a Poison Center member
Are you requesting this data on behalf of a third-party?*

YesNo
Third-Party Name:*
Will the Poison Center be receiving funding for this request?*

YesNo

This form is intended for Poison Center Members (or affiliates collaborating with a sponsoring Poison Center on an unfunded request) only.

To proceed, please click here to complete a Non-Member request:

Non-Member Data Request

Questions? Contact DataRequests@PoisonCenters.org.

You may save and continue completing this form later by selecting "Save" at the bottom of each page. *If you exit this browser without selecting "Save", all responses will be lost.

This form requires a current Poison Center Director or the Central Office Clinical Managing Director's signature of approval. They will be contacted by America's Poison Centers to obtain approval as needed.

NEXT STEPS:

Once this form is complete and reviewed by America's Poison Centers, it will be used to develop the search parameters, pending approval from the Data Access Committee (and Board of Directors, if necessary).
- Please see the Policy for Data Request Approvals and Processing for details (email DataRequests@PoisonCenters.org for assistance locating the policy if needed).
Questions? Contact DataRequests@PoisonCenters.org.

Is this a request to update a previously fulfilled data request?*

Yes, I am requesting to adjust only the date range (extension)Yes, I am requesting to change elements in the original request (not exclusively the date range)No
Topic of previously fulfilled data request:*
Date of Previous Request Submission*

MonthDayYear
If you do not recall, please estimate to the nearest month and year.

SECTION C: DATA REQUEST DESCRIPTION

Please be as specific as possible when completing this section, as these responses will be used to determine whether your request is approved by reviewers.
1. Describe your request, including objectives and methods:*
Please be as specific as possible, as this information will be reviewed during the internal approvals process.
2. Describe how the data will be used and/or disclosed:*
Please be as specific as possible, as this information will be reviewed during the internal approvals process.
3. Describe how the research project will directly support/enhance the research or patient care functions of the member Poison Center, America's Poison Centers, or health care practitioners providing toxicological triage, diagnosis, or management of patients:*
4. Comments or additional data query parameters/requirements:

SECTION D: DATA QUERY PARAMETERS

PART I: GENERAL
PLEASE NOTE:

All National Poison Data System® (NPDS) data reported by America's Poison Centers® during the year in which the exposures occur is considered preliminary because it is possible that a Poison Center may update a case anytime during the year if new information is obtained. Changes occur in only a small number of cases each year. In the fall of each year the data for the previous year is locked, and no additional changes are permitted.
1.Date Range (multiple improvements were made in 2000 - comparisons to data prior to 2000 require special consideration):
Date* to Date*
1.Date Range for data extension (multiple improvements were made in 2000 - comparisons to data prior to 2000 require special consideration):
Date* to Date*
2a. Substances - List trade name(s) and/or generic name(s):*
List ALL substances of interest.
2b. Substances - List America's Poison Centers Generic Codes:*
Poison Center Members may access Generic Codes by searching in Micromedex or the Help Menu in NPDS. Please indicate in the box above if you do not have access. If you prefer to upload an excel or word file in question 2d below, please enter "see 2d".
2c. Substances - List Poisindex Product Codes:*
Poison Center Members may access product codes by searching in Micromedex. Please indicate in the box above if you do not have access. If you prefer to upload an excel or word file in question 2d below, please enter "see 2d".
2d. Substances - Upload Product/Generic Codes List (OPTIONAL)

Please upload a list of codes if codes were not entered in question 2b and/or 2c above.
Cancelof
2e. Substances - If requesting more than one substance, include:*

Records that have either one substance/product ID code/generic code or another ("OR" clause; cases which involve ethanol OR cocaine) (RECOMMENDED)Records that have a combination of substances/product ID codes/generic codes only ("AND" clause; cases which involve ethanol AND cocaine)I'm not requesting more than one substance
2f. Substances - Indicate preference:*

Single and multiple substance casesSingle substance cases
3. Case Status (select all that apply):*

Closed (all Poison Center follow up on the case is complete)Open (case is still being actively followed/updated by the Poison Center)
4. Transferred Cases (between Poison Centers):*

Single record for cases that were transferred (DEFAULT)Multiple records for cases that were transferred

REVIEW & SUBMIT

America's Poison Centers Board of Directors recognizes the importance of Poison Center use of NPDS data for teaching, research, and patient care. NPDS is the one and only repository of NPDS data. The Board recognizes that large datasets either by time or large sections of generic or product codes can inadvertently impair NPDS' ability to be the one and only NPDS data repository.
Email Address of Poison Center Director who will be sponsoring and approving this request:*
example@example.com
Please SKIP the section below, and select SUBMIT. This form will be emailed to the sponsoring Poison Center Director for review and signature of approval. They may elect to edit this request as needed.

TO BE COMPLETED BY POISON CENTER DIRECTOR OR CENTRAL OFFICE CLINICAL LEADERSHIP ONLY:
1. Please review and confirm the following:*

I acknowledge that these data are being provided by America's Poison Centers because of the requestor's affiliation with a member Poison Center, that these data are proprietary and that the associated fee for access to this data is being waived solely because of the direct affiliation with a member center.I acknowledge that if, after the requested data have been provided, the data are subsequently provided to outside non-Poison Center affiliated persons or entities without a member associated with the original request, this will be considered a violation of the member agreement to access full NPDS data.I acknowledge that if it is learned that provided data have been used by a non-Poison Center affiliate for commercial use, research use or publication by a non-affiliate with no acknowledged Poison Center affiliation, a retroactive data fee may be charged to the original requestor.
2. Poison Center Director or Central Office Clinical Leadership Signature:*

Clear
By signing this form, I (the Poison Center Director or Central Office Clinical Leadership), on behalf of the requestor and all collaborators, agree to the stipulations outlined on this page.
Should be Empty:

National Poison Data System®

SECTION A: REQUESTOR INFORMATION

SECTION C: DATA REQUEST DESCRIPTION

SECTION D: DATA QUERY PARAMETERS

SECTION D: DATA QUERY PARAMETERS

SECTION D: DATA QUERY PARAMETERS

SECTION E: DATA OUTPUT TYPE

SECTION F: FATALITY ABSTRACT REQUEST

REVIEW & SUBMIT