American College Health Association-National College Health Assessment II:Lehigh University Institutional Data Request and Disclaimer FormPlease complete this form in its entirety. Incomplete requests will not be processed. You must have JavaScript enabled to use this form. First Name Last Name Email Address Phone Number Role on Campus Undergraduate Student Graduate Student Faculty Staff Other If other, please describe: School or Department Reports/Data Requested Selected Undergraduate Data Selected Graduate Data Please indicate the survey items by year of data collection for which you are requesting data Request #1 Request #2 Request #3 Additional Reports/Data Lehigh Institutional Executive Summary, indicate year(s): Lehigh Institutional Full Data Report, indicate year(s): De-identified SPSS Data File*, indicate year(s): Describe the primary purpose for your request (describe how you will use the data) Describe how you will ensure confidentiality of the data, including how the data will be stored, who will be using the data, etc. Describe how you will disseminate the data (describe how you will share the data) Are you expecting to publish this analysis? Yes No If yes, please state the source/journal If you expect to publish this analysis please refer to the Lehigh University Institution Review Board Guidelines: Human Subject document Date requested by (please allow for a 2 week turnaround) DeclarationIn order to use the ACHA-NCHA II data set provided by Lehigh’s Health Advancement & Prevention Strategies Office, users must agree to abide by the following guidelines. Users shall:Use the data solely for the specified statistical analysis and the reporting of aggregate information;Delete electronic data and shred print data at the conclusion of the study;List at least one member of Health Advancement & Prevention Strategies staff as co-author on any publications resulting from the research; Consider whether a breach of confidentiality is likely due to a low cell count and make no use of the identity of any person discovered inadvertently;Refrain from distributing the datasets to any individual not named on this form without written consent from the Health Advancement & Prevention Strategies office;Be aware that any use of this data implies consent to our data use agreement;Send a copy of any written report to Health Advancement & Prevention Strategies office or to inhaps@lehigh.eduThe accuracy of the user’s statistical analysis and the findings they report are not the responsibility of the Health Advancement & Prevention Strategies office. We shall not be held liable for improper or incorrect interpretation of the data. By signing this form, I hereby certify that I understand the preceding terms and provisions. I fully accept the responsibility for the use of the Lehigh University ACHA-NCHA II data provided to me.The suggested citation for publication will be provided with your data report. I have read and understand the above information: I agree For more information please contact the Health Advancement and Prevention Strategies Office at inhaps@lehigh.edu or 610-758-0275.
