CATRAC Data Request Form

CATRAC Data Request Form

This form ensures that all requests for aggregated data align with the CATRAC Bylaws, Data Governance Guidelines, Performance Improvement framework, and Programs Participation & Data Sharing Agreement (including BAA). Data may only be used to support regional system performance improvement, education, or operational decision-making, not for research, publication, or external dissemination.
Requester Information
Requester's Full Name

First NameLast Name
Organization/Agency Name
Title/Position
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Data Request
Select the purpose that best fits your need:

Other
Note: Research, publication, or use of data outside CATRAC’s internal committees/workgroups and approved stakeholders is not permitted under this process.
Justification and Intended Use
What is the reason for this request?
Describe what question or problem this data will help address.
How will this data be used?
Explain how the data will be presented for quality improvement or educational planning.
How does this request contribute to improvement in the regional healthcare system?
Describe how this aligns with patient care, preparedness, or performance goals across the region.
Data Scope & Specifications
Requested Dataset(s) Analysis

Other
Data Elements/Metrics Requested
List specific measures or metrics—e.g., offload times, scene-to-door intervals, transfers, etc.
Time Frame Requested: Date Range
Governance & Compliance
Data Use Agreement By submitting this form, the requester affirms the following:

- I understand that all data will be aggregated and contain no personally identifiable or protected health information.

- The data will be used solely for CATRAC-approved performance improvement, operational, or educational purposes.

- I will not share, publish, or present this data outside approved CATRAC committees or workgroups without written authorization.

- I agree to comply with CATRAC’s Bylaws (Article IX – Data & PI Committees), Data Governance Guidelines, and Programs Participation and Data Sharing Agreement.
Signature of Requester (Type your name or sign below)
Should be Empty:

CATRAC Data Request Form

Requester Information

Type of Data Request

Justification and Intended Use

Data Scope & Specifications

Governance & Compliance