NCHA Data Request Form

First Name *

Last Name *

Email Address *

Phone Number

(ex: 123-555-9876)

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:

e.x. 2014 survey, items 2-6; 16-21

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):

* Complete raw datasets will not be provided in order to protect the privacy of participants.

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.:

Are you expecting to publish this analysis?

Yes

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):

Year

Month

Day

Declaration

In 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.edu

The 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.

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National College Health Assessment II: