Form #2 Form #2 Data Use Agreement

Nursing Home Survey on Patient Safety Culture Database
Data Use Agreement
Instructions
1. The language contained in this agreement cannot be edited or altered in any form without
permission.
2. Data collection vendors may not sign and submit this Data Use Agreement on behalf of a health
system or Nursing Home (even if they have been given permission by the health system or
Nursing Home to handle the actual submission of data). Only a duly appointed representative from
a health system or Nursing Home may sign this Data Use Agreement.
3. Please return this signed Data Use Agreement by mail, or fax a signed copy to:
Dawn Nelson
Westat
RA 1161
1600 Research Boulevard
Rockville, MD 20850
Fax: 1-888-852-8277 (toll free)
Phone: 1-888-324-9790 (toll free)
Email: [email protected]
4. Once the Data Use Agreement is accepted it will be signed by Westat and we will mail a signed
copy back to you.

Nursing Home Survey on Patient Safety Culture Database
Data Use Agreement
1.

This Data Use Agreement (DUA) is made by and between Westat and the organization named below (hereinafter termed
“Participating Organization”), which includes any nursing homes listed under item 11 on page 2 of this Data Use
Agreement.
__________________________________________________________________________________
Name of Nursing Home (or System/Chain Name if more than one nursing home is included in this DUA)
_________________________________________________________________________________
Street Address of Nursing Home (or System/Chain headquarters location)
_________________________________________________________________________________
City
State
Zip Code
VERY IMPORTANT: Type or write in the name of the Participating Organization above. If more than one
nursing home is represented, list the name of the overall system or chain above, and under item 11 on page 2 of this
Data Use Agreement, IDENTIFY EACH INDIVIDUAL NURSING HOME LOCATION for which data will be
submitted.

2.

This DUA specifies the terms and conditions of Participating Organization’s submission of its Nursing Home Survey on
Patient Safety Culture (NH SOPS) data to Westat for participation in the NH SOPS Comparative Database (hereinafter
termed the “Database”).

3.

The purpose of the Database is to establish a central repository of NH SOPS survey data to facilitate comparisons across
health care organizations. The Database will be populated with NH SOPS survey data through the voluntary participation
of organizations that have implemented the NH SOPS survey and are willing to submit their NH SOPS survey data to
Westat for inclusion in the Database.
The Database is funded by the Agency for Healthcare Research and Quality (AHRQ) under a contract and the Database is
managed and administered by Westat, a private research organization under contract with AHRQ. Westat will operate the
Database to comply with the provisions in this DUA. Within this framework, Westat will manage and administer the
Database using its discretion as necessary, and it will seek and be guided by the advice and counsel of the SOPS Database
Technical Expert Panel (TEP) established by Westat, in accordance with its contractual obligations, to obtain Panel input
throughout the design, development and administration of the Database. The TEP consists of 12 representatives
knowledgeable about hospital, medical office, and nursing home patient safety and quality from various stakeholder
organizations, research institutions, and selected health care systems as well as government agencies concerned with
patient safety and health care.

4.

Participating Organizations will provide their NH SOPS survey data to the Database for analysis and reporting according
to the terms specified in this DUA. By agreeing to participate in the Database, each Participating Organization agrees to
make a good faith effort to provide data, as specified by the data specifications outlined below, for inclusion in the NH
SOPS Database (this data being collectively referred to as the “Data”), including:
a)

A copy of the final NH SOPS survey instrument(s) administered, including copies of paper and/or web-based versions
as applicable, showing all survey instructions and items administered. If more than one version of the NH SOPS
survey was administered, a copy of each NH SOPS survey instrument administered must be provided with the
corresponding results for each version of the survey instrument for which data is submitted;

b) Participating Organization’s final, respondent-level NH SOPS survey data, as collected by Participating Organization
itself or by a survey data collection vendor, according to the data specifications outlined for the Database; and
c)

Selected organizational characteristics data (e.g., bed size, ownership, etc.) and background information related to
survey administration (e.g., mode of survey administration, dates of administration, sample size, response rate, etc.).

Data Use Agreement –Nursing Home Survey on Patient Safety Culture Database

Page 1 of 3

5. Westat agrees to establish appropriate and necessary administrative, technical, and physical procedures and safeguards to
protect the data. Only Westat and duly authorized representatives appointed by AHRQ will have access to the identifiable
source data provided by a Participating Organization. In addition, Westat will ensure appropriate staff training to protect
the confidentiality of the identifiable data and to prevent unauthorized access to it and any unauthorized use of it.
6.

Participating Organization’s Data will be accepted into the Database provided that the version of the NH SOPS survey
administered by Participating Organization is deemed acceptable by Westat (i.e., not modified substantially from the
original NH SOPS instructions and items). Westat will promptly notify Participating Organization of any problem, if any,
with the survey version(s) administered or with the data submitted. If the survey version administered is acceptable but the
data submitted are problematic, Westat will make a good faith effort to work with the Participating Organization to
complete or correct the Data submission, but reserves the right to not include incompatible or flawed data in the Database.

7. Participating Organization’s data files will be aggregated for comparative purposes along with other Participating
Organizations’ Data in the Database. Westat will produce a NH SOPS Comparative Database Report providing aggregate
statistics on NH SOPS survey composite scores and items across all Participating Organizations and across various subsets
of Participating Organizations (e.g., bed size, ownership, etc.). The Report will not identify individual Participating
Organizations by name. Only aggregate data will be reported, and only when there are sufficient data so that such
aggregation will not permit the identification of Participating Organizations by other Participating Organizations or the
public. The Database Report will be made available to Participating Organizations and the public through electronic media
and at no charge. The Database Report will be in the public domain and may be reproduced without permission.
8.

Westat may conduct psychometric analyses of the aggregate data to examine its distributional properties (variability,
missing data, skewness), and to assess the factor structure and reliability of the safety culture dimensions. In any data
analysis reports that may be produced, such reports will not identify individual Participating Organizations by name and
results will only be reported in a manner that will not permit the identification of Participating Organizations.

9.

Westat may grant access to Participating Organization’s data files for health care research purposes approved by AHRQ
and in accordance with the AHRQ confidentiality statute [at 42 USC 299c-3(c)] according to the following provisions:
a)

Access to aggregate data files that do not identify individual Participating Organizations or permit reidentification
may be granted by Westat without the specific authorization of Participating Organizations whose data are included
as part of the aggregate data files. These data files may include variables describing the Participating Organization
according to types (e.g., bed size, ownership, etc.), provided the variables do not permit reidentification.
b) Access to data files specific to an identifiable Participating Organization may be approved only with the express
written authorization of the Participating Organization whose data files are requested. Researcher analyses of the data
files provided to researchers under these provisions and containing any identifying information, may not be released,
disclosed or made public by the researchers without the express written authorization of any Participating
Organizations that may be identified in the published research analysis.
10. Westat agrees to use the Data submitted by Participating Organization only for the purposes stated in this agreement.
11. If Participating Organization represents more than one nursing home, use the space below to TYPE OR WRITE
THE NAME OF EACH INDIVIDUAL NURSING HOME AND ITS ADDRESS, CITY AND STATE which is
represented by Participating Organization and therefore covered under this Data Use Agreement. Attach
additional sheet if necessary.
NAME(S) OF NURSING HOME(S) REPRESENTED

Data Use Agreement –Nursing Home Survey on Patient Safety Culture Database

ADDRESS, CITY & STATE

Page 2 of 3

PLEASE SIGN, COMPLETE THE INFORMATION BELOW, AND FAX OR MAIL ALL PAGES OF THIS DATA
USE AGREEMENT BACK TO WESTAT.
The undersigned individual hereby attests that he/she is duly authorized to represent the Participating Organization and all
nursing homes listed under item 11, and in so doing, enters into this Data Use Agreement on behalf of the Participating
Organization and the nursing homes listed under item 11 and agrees to all the terms specified herein.
Name: _______________________________________________________
Title: ________________________________________________________
_______________________________________________
(Signature)

______________________________
(Date)

Name and address of person from Participating Organization who should be sent the completed Data Use Agreement once it is
signed by Westat:
Name of contact (if different from above):____________________________________________
Title (if different from above): _____________________________________________________
Address: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Phone number: _________________________________
Fax number: ___________________________________
Email address: ___________________________________________

THIS SECTION TO BE COMPLETED BY WESTAT AFTER IT RECEIVES PARTICIPATING ORGANIZATION’S
COMPLETE AND SIGNED DATA USE AGREEMENT.
The undersigned individual hereby attests that he/she is duly authorized to represent Westat in entering into this Data Use
Agreement and in agreeing to all the terms specified herein on their behalf.
W. Sherman Edwards
Vice-President, Westat
___________________________________________
(Signature)
___________________________________________
(Date)

Data Use Agreement –Nursing Home Survey on Patient Safety Culture Database

Page 3 of 3