Application for Data Request Form

Please ensure you have read the ATR Data Access Policy and ATR Fees Policy before completing this online form.

If you wish to complete offline - download the Data Request Form here.

Name *
Name
Contact Phone Number
Contact Phone Number
(optional)
Reason for Request *
Please note that all data is provided according to the AusTQIP-ATR Data Access Policy.
If request above selected Other, then provide details of reason for your request.
Please provide details of the storage of the data
Please provide details of the destruction schedule of the data e.g. the anticipated date and method of destruction
Ethics *
If data is to be used for research purposes, has Research and Ethics approval been obtained from the appropriate committee?
Fees *
All data extractions, basic tabulations, summaries and analyses provided may incur a fee as per the Fees for Provision of Data Policy, see attached. Please read and sign as instructed.
Declaration by Researchers and Research Coordinators
ALL MUST BE AGREED
Avail: 1st Jan 2010 – 31 Dec 2016 (ensure month is not represented by number)
Age Range *
Gender *
Firearms; motorcyclists; or specified ICD10 external cause codes
Regions *
Note: Please see the Specific Access Guidelines in the Data Access Policy for requests that will identify a particular hospital or hospitals.
All, or specific ICD10AM Procedural Codes. Block 954 & 90346-00; procedures for compound skull # i.e. 39609-00 & 39609-01 & 39612-00 & 39609-02 & 39612-01
Injury Regions Head/ Face/ Chest/ Abdomen/ Extremity/ External.. or Any code in head region i.e. 1NNNNN.N; chest injuries with severity 6 i.e. unsurvivable = 4NNNNN.6
BNTMDS Values *

Optional Application Form via .pdf