2. Name of requestor:
  3. Name of organization:
  4. Type of organization:
  6. Phone number:
  7. Email address:
  8. Purpose of request (Objective Statement):
  9. Provide a detailed description of how will the data be used. Any data Ontario Health provides can only be used for the purpose outlined here.
  10. Intended audience:
  11. Data type seen by audience:
  12. Please indicate if Ontario Health has the methodology for the data you are requesting.
  13. If you have been in contact with someone from Ontario Health to discuss your request please provide a contact name. 

  14. Preferred data delivery date (please see Request Fulfilment Timeline description at Request Health Care Data):

  15. Data type being requested:
  16. List of data elements, if applicable:
  17. Data source(s):
  18. Data timeframe (E.g. fiscal 2014/15):
  19. Summary data elements, if applicable (E.g. visit counts, wait times in days etc.):
  20. Grouping of data elements, if applicable (E.g. by month, by disease site, by gender, etc.):
  21. Please indicate if there are exclusion criteria to the data (E.g. age groups, regions):
  22. Other filtering criteria, if applicable (E.g. only patients with ICD10 diagnosis of C50):
  23. Report format (Please attach a template table for how the data should be presented):
  24. Date:

  25. Acknowledgements
  28. Submit

Richard Test 3: Ontario Health does not provide direct patient care or medical advice based on individual cases. Do not include personal health information in your message.

Warning! You cannot save a partially completed form to return to later. Gather all the information and supporting documents you need before you begin.

When to use this form

Use this form to request aggregate or published Ontario Health data to support health system management and planning. It may also be used to request aggregate or published data in advance of a grant submission. 

    Your privacy matters. For more information, please visit our website Terms and Conditions.