Document e7xaY08pynwXNM5ZwYmZeq0Je

JANr02--1900 17:34 CHEMICAL MANUFACTURERS ASSOCIATION FAX Cover Sheet P.001 To: CSftflteL J&lfelO Company: ifixO______________ Telephone#: ______________________ Fax Number From: f^QS Shal/\. Chemical Manufacturers Association (202)887-12|lL Number of Pages (including cover sheet) , G? OeofTondMari: fYX Tkcs ojci5 5&it~ \o -for Ccmfil&h'<nn ) JPfi-02-1900 17=34 STATE OF NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC HEALTH SERVICES BUREAU OF VITAL STATISTICS 6 HAZEN DRIVE, CONCORD, NH 03301-6527 TDDAccess; RelayNH 1-800-735-2964 Agency Phone 603-271-4651 P.002 June 13, 1995 Hasmukh C. Shah, Ph.D. D.A.B.T. Manager, Vinyl Chloride Panel Chemical Manufacturers Association 2501 M Street, NW Washington, DC 20037 Dear Dr. Shah: Enclosed is the necessary application that needs to be completed before any search for records filed at the Bureau can be performed. Please have this application filled out by AEI. This application needs to be completed before your request dated March 1, 1995 can be responded to. To avoid any delay in the processing of your request, please make certain that all items have been completed and the form signed and returned to: Bureau of Vital Records and Health Statistics Health and Welfare Building 6 Hazen Drive Concord, NH 03301 If you have any questions in this regard, please fed free to contact me at (603) 271-4651. Sincerely, KG/mjci26 Karen Grady Acting State Registrar and Chief Bureau of Vital Records and Health Statistics R&S152878 PUBLIC HEALTH OUR BEST RESOURCE jflH-02-1900 17:35 P.003 STATE OF NEW HAMPSHIRE Department of Health and Human Services Division of Public Health Services Bureau of Vital Reconls and Health Stadsdcs - REQUEST FOR VITAL EVENTS RECORD DATA - A. INDIVIDUAL AND ORGANIZATION REQUESTING RECORD DATA 1. Project Director: _! Title: 2. Office, Division. Department, etc.:___________________________1_____________________ 3. Organization:________________________________________________________________ ;___ 4. Street Address or P.O. Box:________________________________________________________ 5. City. State, Zipcode:___________________________________________________________ _ 6. Telephone Number (Include Area Code):________________________________ :_________ 7. Other contact person if more Information is needed:________________________________ 8. Date of Request:________________________ ,_________ _______________________________ REQUESTED DATA 1. Type of record dota requested: [~1 Birth I | Death | ) Marriage 2. Form of requested data: I [Copies of Documents f~] Magnetic Tope | | Divorce (~1 Diskette 3. Time Period of requested data:_________________________________ ; 4. If copies of documents are requested, please complete attached payment Information form. 5. if record data on magnetic tape/diskette are requested/see attachment Bsting data items and check it ms requested. C. TITLE OF STUDY OR PROJECT: -------------- FOR OFFICE USE ONLY Date request received:._________________ __________________ Request: Q Approved Q Disapproved Date of Approval/Disapproval: State Registrar's Signature: _______________________________ _ -1- 3J 9 CD CJ1 TO 3 CD JftN-02-1900 17=35 P.004 In answering the following questions, please be brief but as complete as possible and attach a copy of your research/study/project mrotocol. If you require additional space f r answers please attach a separate page(s) and number each answer. D. SUMMARY OF RESEARCH/STUDY PROTOCOL OR PROJECT ACTIVITIES l. Describe the health or medical probiem(s) addressed by your research/study. What are the primary objectives? State hypotheses to be tested. Z Summarize the research/study/project activities. Indicate specifically each way In which the Informa tion on the records you have requested will be used. 3. Win the activities involve any type of foRowback to contact ony of the persons who are the subjects of the records or who ore named In the records? Q No Q Yes If yes. can you modify your research to exdude followback? Q No ____ % Yes If no, please explain why followback cannot be excluded: DO Cn crooonoo o JflN-02-1900 17=35 P.005 New Hampshire - REQUESTOR ASSURANCES - The undersigned agrees to the following terms and conditions related to this request for vital record data. A. 7h record data shall not be used for any purpose other than that specified in this request. B. No data, statistics or Information derived from the record data which Identifies Individuals shall be published or released In any form and no derived tabular data or statistics prepared for publication or public presentation or distribution of research/study results, shall display celts with frequencies of fewer than three, or information that allows the derivation of c Us with fr quencles of fewer than three, when a single town Is the unit of analysis. C. No r cord data or copies of the record data shall be further released to any other party without the' written consent of th New Hampshire Bureau of Vital Records and Health Statistics. 0. A c py of any report using data or statistics derived from the record data which has been prepared for publication, or public presentation or distribution shall be provided to the New Hampshire State Registrar otVital Statistics priorto release. for the review of any statements describing the technical aspects of the data or statistics. E. Any report using data or statistics derived from the record data which has been prepared for publication, or public presentation or distribution shall: 1. acknowledge the Bureau of Vital Records and Health Statistics of the New Hampshire Division of Public H alth Services as the data source along with a disclaimer on behalf of the Bureau and the Division with respect to any conclusions, estimates or interpretations which the authors have made from the data. Z state any relevant qualifications In Interpretations of the data or statistics as for example, when data observa. ttons do not satisfy conditions required for statistical tests of significance. fTh record data provided to the requestor shall remain Ihe property of the Bureau of Wat Records ond Health Statistics of the New Hampshire Division of Public Health Services. G. All record data provided to the requestor shall be destroyed within one year of the conclusion of the research/study project or. at a later date ifthe State Registrar has approved a written requestfor on extension ofthe time. In either case, whenth r cordshavebeendestroyedtherequestorshailsonotifytheStateRegisfrorbymeansofanotarizedstatem nt. H. I have reviewed the request form. All statements made in the request form are true, complete and correct to the best of my knowledge and belief. Name of principal investigator or project officer Name of official authorized to execute agreements Title Title Organization Organization Jpiatur Date Signature Date R&S152881 *3' 3/6/91 JANr02--1900 17:36 v P.006 - REQUEST FOR COPIES OF DOCUMENTS: PAYMENT INFORMATION - 1, Project Director Title: 2. Organization; '-------------------------------------------------------------------- --------------------------------------------------------------- 3. Type of organization requesting copies of documents: (check all that apply) I I Non-profit n State Funded I | Federally Funded Q Privately funded 4. How often will copies be required? | [Weekly f~]Monthly | [Annually | | Other.Specify 5-.--l low do you prefer to be-toBtod-for-the-eopies?| [Per Botch------------- FI Monthly- Project Director's Signature;, Date: 4- - TOTRL P.006 R&S152882