HomeMy WebLinkAboutWashington State Department of Health (DOH) re Data Sharing- 121922J
DATA SHARING AGREEMENT
DSA Contract # :19 JEF-COVIDVax-0
COVID Vaccine Data
FOR
CONFIDENTIAL INFORMATION OR LIMITED DATASET(S)
BETWEEN
STATE OF WASHINGTON DEPARTMENT OF HEALTH
AND
JEFFERSON COUNTY PUBLIC HEALTH
This Agreement documents the conditions under which the Washington State Department of
Health shares confidential information or limited Dataset(s) with other entities.
CONTACT INFORMATION FOR ENTITIES RECEIVING AND PROVIDING INFORMATION
INFORMATION RECIPIENT
INFORMATION PROVIDER
Organization Name:
Jefferson County Public Health
Washington State Department
of Health (DOH)
Contract Manager Name:
Denise Banker
Sonja Morris
Title:
Community Health Director
COVID-19 Operations Supervisor
Address:
615 Sheridan St
Port Townsend, WA
PO Box 47843
Olympia, WA 98504
Telephone:
360-385-9438
360-236-3545
Email Address:
dbanker@co.jelLerson.wa.us
5onia.Morris@Ddoh.wa.r2v
Data User Contact Name:
Ocean Mason
Meredith Cook
Title:
Public Health Nurse
Epidemiologist
Address:
615 Sheridan St
Port Townsend, WA 98368
PO Box 47843
Olympia, WA 98504
Telephone:
360-379-4480
360-236-3381
Email Address:
omason@co.iefferson.wa.us
meredith.cook@doh.wa.Rov
IT Security Contact Name:
DJ Dimick
John Weeks
Title:
Network Administrator
Chief Information Security
Officer
Address:
615 Sheridan St
Port Townsend, WA 98368
PO Box 47890
Olympia, WA 98504-7890
Telephone:
360-385-9246
360-999-3454
Email Address:
dolsen@co.jefferson.wa.us
Securitv@dohma.gov
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Privacy Contact Name:
Veronica Shaw
Jennifer Brown
Title:
Deputy Director
DOH Chief Privacy Officer
Address:
615 Sheridan St
Port Townsend, WA 98368
P. O. Box 47890
Olympia, WA 98504-7890
Telephone:
360-385-9409
1 (360) 236-4437
Email Address:
I veronica@co.iefferson.wa.us
I Privacv.officer@dohma.> ov
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DEFINITIONS
Authorized user means a recipient's employees, agents, assigns, representatives, independent
contractors, or other persons or entities authorized by the data recipient to access, use or
disclose information through this agreement.
Authorized user agreement means the confidentiality agreement a recipient requires each of its
Authorized Users to sign prior to gaining access to Public Health Information.
Breach of confidentiality means unauthorized access, use or disclosure of information received
under this agreement. Disclosure may be oral or written, in any form or medium.
Breach of security means an action (either intentional or unintentional) that bypasses security
controls or violates security policies, practices, or procedures.
Confidential information means information that is protected from public disclosure by law.
There are many state and federal laws that make different kinds of information confidential. In
Washington State, the two most common are the Public Records Act RCW 42.56, and the
Healthcare Information Act, RCW 70.02.
Data storage means electronic media with information recorded on it, such as CDs/DVDs,
computers and similar devices.
Data transmission means the process of transferring information across a network from a sender
(or source), to one or more destinations.
Direct identifier Direct identifiers in research data or records include names; postal address
information ( other than town or city, state and zip code); telephone numbers, fax numbers, e-
mail addresses; social security numbers; medical record numbers; health plan beneficiary
numbers; account numbers; certificate /license numbers; vehicle identifiers and serial numbers,
including license plate numbers; device identifiers and serial numbers; web universal resource
locators ( URLs); internet protocol (IP) address numbers; biometric identifiers, including finger
and voice prints; and full face photographic images and any comparable images.
Disclosure means to permit access to or release, transfer, or other communication of
confidential information by any means including oral, written, or electronic means, to any party
except the party identified or the parry that provided or created the record.
Encryption means the use of algorithms to encode data making it impossible to read without a
specific piece of information, which is commonly referred to as a "key". Depending on the type
of information shared, encryption may be required during data transmissions, and/or data
storage.
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COVID Vaccine Data
Human subjects research; human sublect means a living individual about whom an investigator
(whether professional or student) conducting research obtains (1) data through intervention or
interaction with the individual, or (2) identifiable private information.
Identifiable data or records contains information that reveals or can likely associate the identity
of the person or persons to whom the data or records pertain. Research data or records with
direct identifiers removed, but which retain indirect identifiers, are still considered identifiable.
Limited dataset means a data file that includes potentially identifiable information. A limited
dataset does not contain direct identifiers.
Potentially identifiable information means information that includes indirect identifiers which
may permit linking an individual to that person's health care information. Examples of potentially
Identifiable information include:
• birth dates;
• admission, treatment or diagnosis dates;
healthcare facility codes;
• other data elements that may identify an individual. These vary depending on factors
such as the geographical location and the rarity of a person's health condition, age, or
other characteristic.
Restricted confidential information means confidential information where especially strict
handling requirements are dictated by statutes, rules, regulations or contractual agreements.
Violations may result in enhanced legal sanctions.
State holidays State legal holidays, as provided in RCW 1.16.050.
Health care information means any information, whether oral or recorded in any form or
medium, that identifies or can readily be associated with the identity of a patient and directly
relates to the patient's health care...." RCW 70.02.010(7)
Health Information is any information that pertains to health behaviors, human exposure to
environmental contaminants, health status, and health care. Health information includes
health care information as defined by RCW 70.02.010 and health related data as defined in
RCW 43.70.050.
Health Information Exchange (HIE) means the statewide hub that provides technical services
to support the secure exchange of health information between HIE participants.
Human research review is the process used by institutions that conduct human subject
research to ensure that:
the rights and welfare of human subjects are adequately protected;
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• the risks to human subjects are minimized, are not unreasonable, and are outweighed
by the potential benefits to them or by the knowledge gained; and
• the proposed study design and methods are adequate and appropriate in light of the
stated research objectives.
Research that involves human subjects or their identifiable personal records should be
reviewed and approved by an institutional review board (IRB) per requirements in federal and
state laws and regulations and state agency policies.
Identifiable data or records: contains information that reveals or can likely associate with the
identity of the person or persons to whom the data or records pertain. Research data or
records with direct identifiers removed, but which retain indirect identifiers, are still considered
identifiable.
Indirect identifiers are indirect identifiers in research data or records that include all geographic
identifiers smaller than a state , including street address, city, county, precinct, Zip code, and
their equivalent postal codes, except for the initial three digits of a ZIP code; all elements of dates
( except year ) for dates directly related to an individual, including birth date, admission date,
discharge date, date of death; and all ages over 89 and all elements of dates ( including year)
indicative of such age, except that such age and elements may be aggregated into a single
category of age 90 or older.
Normal business hours are state business hours Monday through Friday from 8:00 a.m. to 5:00
p.m. except state holidays.
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GENERAL TERMS AND CONDITIONS
I. USE OF INFORMATION
The Information Recipient agrees to strictly limit use of information obtained or created
under this Agreement to the purposes stated in Exhibit I (and all other Exhibits
subsequently attached to this Agreement). For example, unless the Agreement specifies
to the contrary the Information Recipient agrees not to:
• Link information received under this Agreement with any other information.
• Use information received under this Agreement to identify or contact
individuals.
The Information Recipient shall construe this clause to provide the maximum protection
of the information that the law allows.
II. SAFEGUARDING INFORMATION
A. CONFIDENTIALITY
Information Recipient agrees to:
• Follow DOH small numbers guidelines as well as dataset specific small
numbers requirements. (Appendix D)
• Limit access and use of the information:
• To the minimum amount of information.
■ To the fewest people.
■ For the least amount of time required to do the work.
• Ensure that all people with access to the information understand their
responsibilities regarding it.
• Ensure that every person (e.g., employee or agent) with access to the
information signs and dates the "Use and Disclosure of Confidential
Information Form" (Appendix A) before accessing the information.
• Retain a copy of the signed and dated form as long as required in Data
Disposition Section.
The Information Recipient acknowledges the obligations in this section survive
completion, cancellation, expiration or termination of this Agreement.
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B. SECURITY
The Information Recipient assures that its security practices and safeguards meet
Washington State Office of the Chief Information Officer (OCIO) security standard
141.10 Sewrina Information Technology Assets.
For the purposes of this Agreement, compliance with the HIPAA Security Standard and
all subsequent updates meets OICIO standard 141.10 "Securing Information
Technology Assets."
The Information Recipient agrees to adhere to the Data Security Requirements in
Appendix B. The Information Recipient further assures that it has taken steps
necessary to prevent unauthorized access, use, or modification of the information in
any form.
Note: The DOH Chief Information Security Officer must approve any changes to this
section prior to Agreement execution. IT Security Officer will send approval/denial
directly to DOH Contracts Office and DOH Business Contact.
C. BREACH NOTIFICATION
The Information Recipient shall notify the DOH Chief Information Security Officer
(securityowdohma.gm within one (1) business days of any suspected or actual breach of
security or confidentiality of information covered by the Agreement.
III. RE -DISCLOSURE OF INFORMATION
Information Recipient agrees to not disclose in any manner all or part of the information
identified in this Agreement except as the law requires, this Agreement permits, or with
specific prior written permission by the Secretary of the Department of Health.
If the Information Recipient must comply with state or federal public record disclosure
laws, and receives a records request where all or part of the information subject to this
Agreement is responsive to the request: the Information Recipient will notify the DOH
Privacy Officer of the request ten (10) business days prior to disclosing to the requestor.
The notice must:
• Be in writing;
• Include a copy of the request or some other writing that shows the:
• Date the Information Recipient received the request; and
• The DOH records that the Information Recipient believes are
responsive to the request and the identity of the requestor, if
known.
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IV. ATTRIBUTION REGARDING INFORMATION
Information Recipient agrees to cite "Washington State Department of Health" or other
citation as specified, as the source of the information subject of this Agreement in all text,
tables and references in reports, presentations and scientific papers.
Information Recipient agrees to cite its organizational name as the source of
interpretations, calculations or manipulations of the information subject of this
Agreement.
V. OTHER PROVISIONS
With the exception of agreements with British Columbia for sharing health information,
all data must be stored within the United States.
VI. AGREEMENT ALTERATIONS AND AMENDMENTS
This Agreement may be amended by mutual agreement of the parties. Such amendments
shall not be binding unless they are in writing and signed by personnel authorized to bind
each of the parties
VII. CAUSE FOR IMMEDIATE TERMINATION
The Information Recipient acknowledges that unauthorized use or disclosure of the
data/information or any other violation of sections II or III, and appendices A or B, may
result in the immediate termination of this Agreement.
Vlll. CONFLICT OF INTEREST
The DOH may, by written notice to the Information Recipient:
Terminate the right of the Information Recipient to proceed under this Agreement if it is
found, after due notice and examination by the Contracting Office that gratuities in the
form of entertainment, gifts or otherwise were offered or given by the Information
Recipient, or an agency or representative of the Information Recipient, to any officer or
employee of the DOH, with a view towards securing this Agreement or securing favorable
treatment with respect to the awarding or amending or the making of any determination
with respect to this Agreement.
In the event this Agreement is terminated as provided in (a) above, the DOH shall be
entitled to pursue the same remedies against the Information Recipient as it could pursue
in the event of a breach of the Agreement by the Information Recipient. The rights and
remedies of the DOH provided for in this section are in addition to any other rights and
remedies provided by law. Any determination made by the Contracting Office under this
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clause shall be an issue and may be reviewed as provided in the "disputes" clause of this
Agreement.
IX. DISPUTES
Except as otherwise provided in this Agreement, when a genuine dispute arises between
the DOH and the Information Recipient and it cannot be resolved, either party may submit
a request for a dispute resolution to the Contracts and Procurement Unit. The parties
agree that this resolution process shall precede any action in a judicial and quasi-judicial
tribunal. A party's request for a dispute resolution must:
• Be in writing and state the disputed issues, and
• State the relative positions of the parties, and
• State the information recipient's name, address, and his/her department
agreement number, and
• Be mailed to the DOH contracts and procurement unit, P. O. Box 47905,
Olympia, WA 98504-7905 within thirty (30) calendar days after the party
could reasonably be expected to have knowledge of the issue which
he/she now disputes.
This dispute resolution process constitutes the sole administrative remedy available
under this Agreement.
X. EXPOSURE TO DOH BUSINESS INFORMATION NOT OTHERWISE PROTECTED BY LAW
AND UNRELATED TO CONTRACT WORK
During the course of this contract, the information recipient may inadvertently become
aware of information unrelated to this agreement. Information recipient will treat such
information respectfully, recognizing DOH relies on public trust to conduct its work. This
information may be hand written, typed, electronic, or verbal, and come from a variety
of sources.
XI. GOVERNANCE
This Agreement is entered into pursuant to and under the authority granted by the laws
of the state of Washington and any applicable federal laws. The provisions of this
Agreement shall be construed to conform to those laws.
In the event of an inconsistency in the terms of this Agreement, or between its terms and
any applicable statute or rule, the inconsistency shall be resolved by giving precedence in
the following order:
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• Applicable Washington state and federal statutes and rules;
Any other provisions of the Agreement, including materials incorporated by
reference.
XII. HOLD HARMLESS
Each party to this Agreement shall be solely responsible for the acts and omissions of its
own officers, employees, and agents in the performance of this Agreement. Neither party
to this Agreement will be responsible for the acts and omissions of entities or individuals
not party to this Agreement. DOH and the Information Recipient shall cooperate in the
defense of tort lawsuits, when ppssible.
XIII. LIMITATION OF AUTHORITY
Only the Authorized Signatory for DOH shall have the express, implied, or apparent
authority to alter, amend, modify, or waive any clause or condition of this Agreement on
behalf of the DOH. No alteration, modification, or waiver of any clause or condition of
this Agreement is effective or binding unless made in writing and signed by the Authorized
Signatory for DOH.
XIV. RIGHT OF INSPECTION
The Information Recipient shall provide the DOH and other authorized entities the right
of access to its facilities at all reasonable times, in order to monitor and evaluate
performance, compliance, and/or quality assurance under this Agreement on behalf of
the DOH.
XV. SEVERABIUTY
If any term or condition of this Agreement is held invalid, such invalidity shall not affect
the validity of the other terms or conditions of this Agreement, provided, however, that
the remaining terms and conditions can still fairly be given effect.
XVI. SURVIVORSHIP
The terms and conditions contained in this Agreement which by their sense and context,
are intended to survive the completion, cancellation, termination, or expiration of the
Agreement shall survive.
XVIL TERMINATION
Either party may terminate this Agreement upon 30 days prior written notification to the
other party. If this Agreement is so terminated, the parties shall be liable only for
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performance rendered or costs incurred in accordance with the terms of this Agreement
prior to the effective date of termination.
XVIII. WAIVER OF DEFAULT
This Agreement, or any term or condition, may be modified only by a written amendment
signed by the Information Provider and the Information Recipient. Either parry may
propose an amendment.
Failure or delay on the part of either party to exercise any right, power, privilege or remedy
provided under this Agreement shall not constitute a waiver. No provision of this Agreement
may be waived by either party except in writing signed by the Information Provider or the
Information Recipient.
XIX. ALL WRITINGS CONTAINED HEREIN
This Agreement and attached Exhibit(s) contains all the terms and conditions agreed upon
by the parties. No other understandings, oral or otherwise, regarding the subject matter
of this Agreement and attached Exhibit(s) shall be deemed to exist or to bind any of the
parties hereto.
XX. PERIOD OF PERFORMANCE
This Agreement shall be effective from 01/01/2023 through 12/31/2024.
IN WITNESS WHEREOF, the parties have executed this Agreement as of the date of last
signature below.
INFORMATION PROVIDER
State of Washington Department of Health
Signature
Tawney Harper, OI Deputy Director
Print Name
January 5, 2023
Date
INFORMATION RECIPIENT
Jefferf4n Coun Public Health
Signature
Heidi Eisenhour, Chair
Jefferson County Board of Commissioners
Print Name
Dat— e
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EXHIBIT I
1. PURPOSE AND JUSTIFICATION FOR SHARING THE DATA
Provide a detailed description of the purpose and justification for sharing the data, including
specifics on how the data will be used.
The purpose of this Agreement is public health surveillance as it allows for a public health
authority to identify, monitor, assess, or investigate potential public health signals, onsets of
disease outbreaks, or conditions of public health importance. It is therefore exempt from
consideration as research, per federal Common Rule (46 C.F.R. Part 46, Subpart A). Further,
because the purpose of the data sharing under this agreement is not'research' as defined in RCW
42.48.010(4), chapter 42.48 RCW does not apply.
WA DOH will provide patient level COVID-19 vaccine administration level data from the
Washington State Immunization Information System (WAITS). Data will include doses
administered to Jefferson County residents as well as doses administered within Jefferson County
facilities. Additionally, linked COVID-19 case surveillance data (listed in variable list in Appendix
E) will be included when these data become available. Availability of COVID-19 case surveillance
data are still being determined.
Is the purpose of this agreement for human subjects research that requires Washington State
Institutional Review Board (WSIRB) approval?
❑ Yes ® No
If yes, has a WSIRB review and approval been received? If yes, please provide copy of
approval. If No, attach exception letter.
❑ Yes ❑ No
1. Agreement is for a de -identified limited data set: ❑ Yes ® No
2. Data will not be used to re -identify or contact individuals. ® Yes ❑ No
3. Data will not be linked with any other information. ® Yes ❑ No
If any of the criteria above are marked "No", attach an Exempt Determination Request to this
DSA.
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2. PERIOD OF PERFORMANCE
This Exhibit shall have the same period of performance as the Agreement unless otherwise
noted below:
Exhibit shall be effective from through
3. DESCRIPTION OF DATA
information Provider will make available the following information under this Agreement
Database Name(s): Washington State Immunization Information System (WAITS)
Data Elements being provided:
See Appendix E for list of variables that will be made available.
The information described in this section is:
® Restricted Confidential Information (Category 4)
❑ Confidential Information (Category 3)
❑ Potentially identifiable information (Category 3)
❑ Internal [public information requiring authorized access] (Category 2)
❑ Public Information (Category 1)
Any reference to data/information in this Agreement shall be the data/information as
described in this Exhibit.
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4. STATUTORY AUTHORITY TO SHARE INFORMATION
DOH statutory authority to obtain and disclose the confidential information or limited
Dataset(s) identified in this Exhibit to the Information Recipient:
RCW 43.20.050—Powers and duties of state board of health
RCW 43.70.050 — Collection, use, and accessibility of health -related data
RCW 70.02.050 — Disclosure without patient's authorization
WAC 246-101-515 — Handling of case reports and medical information.
Information Recipient's statutory authority to receive the confidential information or limited
Dataset(s) identified in this Exhibit
S. ACCESS TO INFORMATION
METHOD OF ACCESS/TRANSFER
❑ DOH Web Application (indicate application name):
® Washington State Secure File Transfer Service (sft.wa.gov)
❑ Encrypted CD/DVD or other storage device
❑ Health Information Exchange (HIE)**
❑ Other: (describe the methods for access/transfer)**
**NOTE: DOH Chief Information Security Officer must approve prior to Agreement
execution. DOH Chief Information Security Officer will send approval/denial directly to
DOH Contracts Office and DOH Business Contact.
FREQUENCY OF ACCESS/TRANSFER
❑ One time: DOH shall deliver information by (insert date)
® Repetitive: frequency or dates Weeld (insert dates if applicable)
❑ As available within the period of performance stated in Section 2.
6. REIMBURSEMENT TO DOH
Payment for services to create and provide the information is based on the actual expenses
DOH incurs, including charges for research assistance when applicable.
Billing Procedure
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Information Recipient agrees to pay DOH by check or account transfer within
30 calendar days of receiving the DOH invoice.
• Upon expiration of the Agreement, any payment not already made shall be
submitted within 30 days after the expiration date or the end of the fiscal year,
which is earlier.
Charges for the services to create and provide the information are:
Z No charge.
7. DATA DISPOSITION
Unless otherwise directed in writing by the DOH Business Contact, at the end of this
Agreement, or at the discretion and direction of DOH, the Information Recipient shall:
❑ Immediately destroy all copies of any data provided under this Agreement
after it has been used for the purposes specified in the Agreement .
Acceptable methods of destruction are described in Appendix B. Upon
completion, the Information Recipient shall submit the attached
Certification of Data Disposition (Appendix C) to the DOH Business Contact.
❑ Immediately return all copies of any data provided under this Agreement
to the DOH Business Contact after the data has been used for the purposes
specified in the Agreement, along with the attached Certification of Data
Disposition (Appendix C)
® Retain the data for the purposes stated herein for a period of time not to
exceed one year (e.g., one year, etc.), after which Information Recipient
shall destroy the data (as described below) and submit the attached
Certification of Data Disposition (Appendix C) to the DOH Business Contact.
❑ Other (Describe):
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S. RIGHTS IN INFORMATION
Information Recipient agrees to provide, if requested, copies of any research papers or
reports prepared as a result of access to DOH information under this Agreement for DOH
review prior to publishing or distributing.
In no event shall the Information Provider be liable for any damages, including, without
limitation, damages resulting from lost information or lost profits or revenue, the costs of
recovering such Information, the costs of substitute information, claims by third parties or
for other similar costs, or any special, incidental, or consequential damages, arising out of the
use of the information. The accuracy or reliability of the Information is not guaranteed or
warranted in anyway and the information Provider's disclaim liability of any kind whatsoever,
including, without limitation, liability for quality, performance, merchantability and fitness
for a particular purpose arising out of the use, or inability to use the information.
If checked, please submit the following:
• Copies of (insert fist of items)
to the attention of: _(insert name of DOH employee)
at (insert address to which material is sent)
9. ALL WRITINGS CONTAINED HEREIN
This Agreement and attached Exhibit(s) contains all the terms and conditions agreed upon by
the parties. No other understandings, oral or otherwise, regarding the subject matter of this
Agreement and attached Exhibit(s) shall be deemed to exist or to bind any of the parties
hereto.
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IN WITNESS WHEREOF, the parties have executed this Exhibit as of the date of last signature
below.
INFORMATION PROVIDER
State of Washington Department of Health
Signature
Tawney Harper, OI Deputy Director
Print Name
January 5, 2023
Date
Approved as To form only:
December 13, 2022
Philip C. Hunsucker DATE
Chief Civil Deputy Prosecuting Attorney
INFORMATION RECIPIENT
Jeff n Cou y Public Health
Signature
Heidi Eisenhour, Chair
Jefferson County Board of Commissioners
Print Name
i z�j� r2Z
Dace
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EXHIBIT 11
APPROVED SCOPE OF DEATH DATA
1. PURPOSE OF DATA AUTHORIZED BY THE DEPARTMENT
DOH death data contribute to populating a death field in IIS. Requestors will receive IIS data
extracts that include this death field. Requestors are authorized to use this death data for
identifying individuals who should not be contacted during outreach efforts. This could
include filtering out deceased individuals before calculating certain coverage rates and
before sending out reminders about overdue vaccinations (reminder recall).
The Information Recipient is permitted to contact individuals. ❑ Yes ® No
If yes: Contacting individuals that is authorized by the Department.
The data is permitted to be linked with other information. ❑ Yes ® No
If yes: Linking authorized by the Department.
The data is permitted to be re -disclosed. ❑ Yes ® No
If ves: Re -disclosure that is autnorizeo Dy the
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2. DESCRIPTION OF DATA
The Department will make available the following information under this Agreement:
❑ WA Death Annual Statistical
❑ WA Death Cause of Death Literals
® WA Death Names
❑ WA Death Geocode
The information described in this section is:
❑ Restricted Confidential Information (Category 4)
® Potentially Identifiable/Confidential Information (Category 3)
❑ Internal [public information requiring authorized access] (Category 2)
❑ Public Information (Category 1)
Any reference to data/information in this Agreement shall be the data/information as described
in this Exhibit.
3. USE OF INFORMATION
The Information Recipient agrees and understands that, unless stated otherwise in this Exhibit,
it is not permitted to:
• Use the information received under this Agreement for any commercial purposes.
• Sell the information to another individual or organization.
• Share or give information received under this Agreement with anyone not authorized by
the Department or for any reason beyond the purposes stated in this Exhibit.
4. ACCESS TO INFORMATION
METHOD OF ACCESS/TRANSFER
❑ DOH Web Application (indicate application name):
❑ DOH Y: Drive (Internal DOH only)
® Washington State Secure File Transfer Service (sft.wa.gov)
❑ Health Information Exchange (HIE)**
❑ Other: (describe the methods for access/transfer)**
**Note: The Department's Chief Information Security Officer must approve prior to Agreement
execution. The Department's Chief Information Security Officer will send approval/denial directly
to the Department's Contracts Office and Business Contact.
FREQUENCY OF ACCESS/TRANSFER
❑ Repetitive: frequency
® As available or requested.
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S. REIMBURSEMENT TO DOH
The Information Recipient shall pay the Department the applicable fees required by WAC 246-492-
990 for the information provided under this Agreement.
Billing Procedure
Information Recipient agrees to provide payment to the Department before receiving
the data, and understands that the Department will not provide data until payment
has been made.
Upon expiration of the Agreement, any payment not already made shall be submitted
within 30 days after the expiration date or the end of the fiscal year, whichever is
earlier.
6. RIGHTS IN INFORMATION
information Recipient agrees to provide, if requested, copies for review by the Department of
any research papers or reports prepared as a result of access to Department information under
this Agreement prior to publishing or distributing. If requested, submit the copies of any research
papers or reports to the Department's Business Contact listed in this Agreement.
In no event shall the Department be liable for any damages, including, without limitation,
damages resulting from lost information or lost profits or revenue, the costs of recovering such
Information, the costs of substitute information, claims by third parties or for other similar costs,
or any special, incidental, or consequential damages, arising out of the use of the information.
The accuracy or reliability of the Information is not guaranteed or warranted in any way and the
Department disclaims liability of any kind whatsoever, including, without limitation, liability for
quality, performance, merchantability and fitness for a particular purpose arising out of the use,
or inability to use the information.
IN WITNESS WHEREOF, the parties have executed this Exhibit as of the date of last signature
below.
INFORMATION PROVIDER
State of Washington Department of Health
/1�lat&tz�
Signature
Katherine Hutchinson
Print Name
1 /04/2023
Date
INFORMATION RECIPIENT
Jeffer n County Public Health
Signature pp
Print Name l �
Heidi Eisenhour, Chair (Z-
Jefferson County Board of Commissioners
Date
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APPENDIX A
USE AND DISCLOSURE OF CONFIDENTIAL INFORMATION
People with access to confidential information are responsible for understanding and following
the laws, policies, procedures, and practices governing it. Below are key elements:
A. CONFIDENTIAL INFORMATION
Confidential information is information federal and state law protects from public
disclosure. Examples of confidential information are social security numbers, and
healthcare information that is identifiable to a specific person under RCW 70.02. The
general public disclosure law identifying exemptions is RCW 42.56.
B. ACCESS AND USE OF CONFIDENTIAL INFORMATION
1. Access to confidential information must be limited to people whose work
specifically requires that access to the information.
2. Use of confidential information is limited to purposes specified elsewhere in this
Agreement.
C. DISCLOSURE OF CONFIDENTIAL INFORMATION
1. An Information Recipient may disclose an individual's confidential information
received or created under this Agreement to that individual or that individual's
personal representative consistent with law.
2. An Information Recipient may disclose an individual's confidential information,
received or created under this Agreement only as permitted under the Re -
Disclosure of information section of the Agreement, and as state and federal laws
allow.
D. CONSEQUENCES OF UNAUTHORIZED USE OR DISCLOSURE
An Information Recipient's unauthorized use or disclosure of confidential information is
the basis for the Information Provider immediately terminating the Agreement. The
Information Recipient may also be subject to administrative, civil and criminal penalties
identified in law.
E. ADDITIONAL DATA USE RESTRICTIONS: (if necessary)
Signature:
Date:
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APPENDIX B
DATA SECURITY REQUIREMENTS
Protection of Data
The storage of Category 3 and 4 information outside of the State Governmental Network requires
organizations to ensure that encryption is selected and applied using industry standard
algorithms validated by the NIST Cryptographic Algorithm Validation Program. Encryption must
be applied in such a way that it renders data unusable to anyone but authorized personnel, and
the confidential process, encryption key or other means to decipher the information is protected
from unauthorized access. All manipulations or transmissions of data within the organizations
network must be done securely.
The Information Recipient agrees to store information received under this Agreement (the data)
within the United States on one or more of the following media, and to protect it as described
below:
A. Passwords
1. Passwords must always be encrypted. When stored outside of the authentication
mechanism, passwords must be in a secured environment that is separate from the data
and protected in the same manner as the data. For example passwords stored on mobile
devices or portable storage devices must be protected as described under section F. Data
storage on mobile devices or portable storage media.
2. Complex Passwords are:
• At least 8 characters in length.
• Contain at least three of the following character classes: uppercase letters,
lowercase letters, numerals, special characters.
• Do not contain the user's name, user ID or any form of their full name.
• Do not consist of a single complete dictionary word but can include a passphrase.
• Do not consist of personal information (e.g., birthdates, pets' names, addresses,
etc.).
• Are unique and not reused across multiple systems and accounts.
• Changed at least every 120 days.
B. Hard Disk Drives / Solid State Drives — Data stored on workstation drives:
1. The data must be encrypted as described under section F. Data storage on mobile devices
or portable storage media. Encryption is not required when Potentially Identifiable
Information is stored temporarily on local workstation Hard Disk Drives/Solid State Drives.
Temporary storage is thirty (30) days or less.
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2. Access to the data is restricted to authorized users by requiring logon to the local
workstation using a unique user ID and Complex Password, or other authentication
mechanisms which provide equal or greater security, such as biometrics or smart cards.
Accounts must lock after 5 unsuccessful access attempts and remain locked for at least
15 minutes, or require administrator reset.
C. Network server and storage area networks (SAN)
1. Access to the data is restricted to authorized users through the use of access control
lists which will grant access only after the authorized user has authenticated to the
network.
2. Authentication must occur using a unique user ID and Complex Password, or other
authentication mechanisms which provide equal or greater security, such as
biometrics or smart cards. Accounts must lock after 5 unsuccessful access attempts,
and remain locked for at least 15 minutes, or require administrator reset.
3. The data are located in a secured computer area, which is accessible only by
authorized personnel with access controlled through use of a key, card key, or
comparable mechanism.
4. If the servers or storage area networks are not located in a secured computer area or
if the data is classified as Confidential or Restricted it must be encrypted as described
under F. Data storage on mobile devices or portable storage media.
D. Optical discs (CDs or DVDs)
1. Optical discs containing the data must be encrypted as described under F. Data
storage on mobile devices or portable storage media.
2. When not in use for the purpose of this Agreement, such discs must be locked in a
drawer, cabinet or other physically secured container to which only authorized users
have the key, combination or mechanism required to access the contents of the
container.
E. Access over the Internet or the State Governmental Network (SGN).
1. When the data is transmitted between DOH and the Information Recipient, access is
controlled by the DOH, who will issue authentication credentials.
2. Information Recipient will notify DOH immediately whenever:
a) An authorized person in possession of such credentials is terminated or
otherwise leaves the employ of the Information Recipient;
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b) Whenever a person's duties change such that the person no longer requires
access to perform work for this Contract.
3. The data must not be transferred or accessed over the Internet by the Information
Recipient in any other manner unless specifically authorized within the terms of the
Agreement.
a) If so authorized the data must be encrypted during transmissions using a key
length of at least 128 bits. Industry standard mechanisms and algorithms, such
as those validated by the National Institute of Standards and Technology
(NIST) are required.
b) Authentication must occur using a unique user ID and Complex Password (of
at least 10 characters). When the data is classified as Confidential or
Restricted, authentication requires secure encryption protocols and multi -
factor authentication mechanisms, such as hardware or software tokens,
smart cards, digital certificates or biometrics.
c) Accounts must lock after 5 unsuccessful access attempts, and remain locked
for at least 15 minutes, or require administrator reset.
F. Data storage on mobile devices or portable storage media
1. Examples of mobile devices are: smart phones, tablets, laptops, notebook or netbook
computers, and personal media players.
2. Examples of portable storage media are: flash memory devices (e.g. USB flash drives), and
portable hard disks.
The data must not be stored by the Information Recipient on mobile devices or portable
storage media unless specifically authorized within the terms of this Agreement. If so
authorized:
a) The devices/media must be encrypted with a key length of at least 128 bits, using
industry standard mechanisms validated by the National Institute of Standards and
Technologies (NIST).
• Encryption keys must be stored in a secured environment that is separate from
the data and protected in the same manner as the data.
b) Access to the devices/media is controlled with a user ID and a Complex Password (of
at least 6 characters), or a stronger authentication method such as biometrics.
c) The devices/media must be set to automatically wipe or be rendered unusable after
no more than 10 failed access attempts.
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d) The devices/media must be locked whenever they are left unattended and set to lock
automatically after an inactivity activity period of 3 minutes or less.
e) The data must not be stored in the Cloud. This includes backups.
f) The devices/ media must be physically protected by:
• Storing them in a secured and locked environment when not in use;
• Using check-in/check-out procedures when they are shared; and
• Taking frequent inventories.
4. When passwords and/or encryption keys are stored on mobile devices or portable storage
media they must be encrypted and protected as described in this section.
G. Backup Media
The data may be backed up as part of Information Recipient's normal backup process
provided that the process includes secure storage and transport, and the data is encrypted
as described under F. Data storage on mobile devices or portable storage media.
H. Paper documents
Paper records that contain data classified as Confidential or Restricted must be protected by
storing the records in a secure area which is only accessible to authorized personnel. When
not in use, such records is stored in a locked container, such as a file cabinet, locking drawer,
or safe, to which only authorized persons have access.
I. Data Segregation
1. The data must be segregated or otherwise distinguishable from all other data. This is to
ensure that when no longer needed by the Information Recipient, all of the data can be
identified for return or destruction. It also aids in determining whether the data has or
may have been compromised in the event of a security breach.
2. When it is not feasible or practical to segregate the data from other data, then all
commingled data is protected as described in this Exhibit.
J. Data Disposition
If data destruction is required by the Agreement, the data must be destroyed using one or
more of the following methods:
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Data stored on: Is destroyed by:
Hard Disk Drives / Solid State Using a "wipe" utility which will overwrite the data at
Drives least three (3) times using either random or single
character data, or
Degaussing sufficiently to ensure that the data cannot
be reconstructed, or
Physically destroying the disk, or
Delete the data and physically and logically secure data
storage systems that continue to be used for the
storage of Confidential or Restricted information to
prevent any future access to stored information. One
or more of the preceding methods is performed before
transfer or surplus of the systems or media containing
the data.
Paper documents with On -site shredding, pulping, or incineration, or
Confidential or Restricted Recycling through a contracted firm provided the
information Contract with the recycler is certified for the secure
destruction of confidential information.
Optical discs (e.g. CDs or DVDs) Incineration, shredding, or completely defacing the
readable surface with a course abrasive.
Magnetic tape Degaussing, incinerating or crosscut shredding.
Removable media (e.g. floppies, Using a "wipe" utility which will overwrite the data at
USB flash drives, portable hard least three (3) times using either random or single
disks, Zip or similar disks) character data.
Physically destroying the disk.
Degaussing magnetic media sufficiently to ensure that
the data cannot be reconstructed.
K. Notification of Compromise or Potential Compromise
The compromise or potential compromise of the data is reported to DOH as required in
Section II.C.
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APPENDIX C
CERTIFICATION OF DATA DISPOSITION
Date of Disposition
❑ All copies of any Datasets related to agreement DOH# have been deleted from
all data storage systems. These data storage systems continue to be used for the storage
of confidential data and are physically and logically secured to prevent any future access
to stored information. Before transfer or surplus, all data will be eradicated from these
data storage systems to effectively prevent any future access to previously stored
information.
❑ All copies of any Datasets related to agreement DOH# have been eradicated from
all data storage systems to effectively prevent any future access to the previously stored
information.
❑ All materials and computer media containing any data related to agreement DOH
# have been physically destroyed to prevent any future use of the materials and
media.
❑ All paper copies of the information related to agreement DOH # have been
destroyed on -site by cross cut shredding.
❑ All copies of any Datasets related to agreement DOH # that have not been
disposed of in a manner described above, have been returned to DOH.
❑ Other
The data recipient hereby certifies, by signature below, that the data disposition requirements
as provided in agreement DOH # , Section J, Disposition of Information, have been
fulfilled as indicated above.
Signature of data recipient
Date
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APPENDIX D
DOH SMALL NUMBERS GUIDELINES
• Aggregate data so that the need for suppression is minimal. Suppress all non -zero
counts which are less than ten.
• Suppress rates or proportions derived from those suppressed counts.
• Assure that suppressed cells cannot be recalculated through subtraction, by using
secondary suppression as necessary. Survey data from surveys in which 80% or more of
the eligible population is surveyed should be treated as non -survey data.
• When a survey includes less than 80% of the eligible population, and the respondents
are unequally weighted, so that cell sample sizes cannot be directly calculated from the
weighted survey estimates, then there is no suppression requirement for the weighted
survey estimates.
• When a survey includes less than 80% of the eligible population, but the respondents
are equally weighted, then survey estimates based on fewer than 10 respondents
should be "top -coded" (estimates of less than 5% or greater than 95% should be
presented as 0-5% or 95-100%).
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APPENDIX E
DATA ELEMENTS
reWIM1Q Immunisatinn Rpe itn LHl Data nirti[ataty
Field Name
DataType
Field Definition
Field Values
The name of the physical clinic
or facility that reported the
vaccination, refusal, or missed
appointment. In some cases,
this could be the same as the
AdministeredAtLocatlon
varchar(50)
1 responsible organization.
1(Commercial vaccination service provider)
2 (Corrections/detention health services)
3 (Health center —community)
4 (Health center —migrant or refugee)
5 (Health center —occupational)
6 (Health center—STD/HIV clinic)
7 (Health center —student)
8 (Home health care provider)
9 (Hospital)
10 (Indian Health Service)
11(Tribal health)
12 (Medical practice —family medicine)
13 (Medical practice —pediatrics)
14 (Medical practice — internal medicine)
15 (Medical practice — OB/GYN)
16 (Medical practice — other specialty)
17 (Pharmacy —chain)
18 (Pharmacy — independent)
19 (Public health provider — public health clinic)
20 (Public health provider — Federally Qualified Health
Center)
21(Public health provider — Rural Health Clinic)
22 (Long-term care — nursing home, skilled nursing
facility, federally certified)
23 (Long-term care — nursing home, skilled nursing
facility, non -federally certified)
24 (Long-term care — assisted living)
25 (long-term care — intellectual or developmental
disability)
26 (Long-term care — combination)
27 (Urgent care)
The characteristic of the
28 (Other)
provider site that reported the
UNK (Unknown)
AdministeredAtLocationTy
vaccination, refusal, or missed
pe
int
appointment
The city component of where
the vaccine is being
administered/planned to be
administered. For long-term
care facilities, the recipient's
address will be the same as the
administration address. For
mobile clinics, the
administration address should
be where the clinic is being
AdministrationAddressClty
varchar(5o)
held.
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The county component of
where the vaccine is being
administered/planned to be
administered. For long-term
pre facilities, the recipient's
address will be the same as the
administration address. For
mobile clinics, the
administration address should
AdministrationAddressCou
be where the clinic is being
nty
int
held.
The state component of where
the vaccine is being
administered/planned to be
administered. For long-term
pre facilities, the recipient's
address will be the same as the
administration address. For
mobile clinics, the
administration address should
AdministrationAddressStat
be where the clinic is being
e
varchar(2)
held.
The street component of where
the vaccine is being
administered/planned to be
administered. For long-term
pre facilities, the recipient's
address will be the same as the
administration address. For
mobile clinics, the
administration address should
AdministrationAddressStre
be where the clinic is being
et
varchar(50)
held.
The street 2 component of
where the vaccine is being
administered/planned to be
administered. For long-term
pre facilities, the recipient's
address will be the same as the
administration address. For
mobile clinics, the
administration address should
AdministrationAddress5tre
be where the clinic is being
et2
varchar(50)
held.
The zip code component of
where the vaccine is being
administered/planned to be
administered. For long-term
pre facilities, the recipient's
address will be the same as the
administration address. For
mobile clinics, the
administration address should
AdministrationAddressVpC
be where the clinic is being
ode
int
held.
The date the vaccination event
occurred (or was intended to
AdministrationDate
date
occur)
ASIISFACID
int
WAIIS Facirdy ID
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Dose # in vaccination series
provided dose is considered
valid (e.g., counts towards
DoseNumber
lnt
immunity).
WalisinsertDate
datetime
WAILS Vaccination Insert Date
The lot number of the vaccine
administered: Unit of Use (UoU)
Is preferred if both UoU and
LotNumber
varchar(20)
Unit of Sale (UoS) are available.
The manufacturer ofthevaccine
https://www2a.cdc.gov/vacdnes/Osti6standards/vaccin
MVX
varchar(5)
administered
es.a 7r t=mvx
The vaccine type that was
https://www2a.cdc.gov/vaccines/lis/ilsstandards/vamin
CVX
int
administered.
es as 7rpt-m
The vaccine product that was
administered. Unit of Use (UoU)
Is preferred if both UoU and
httPs://www2a.cdc.gov/vaccines,41s/lisstandards/ndq_c
NDC
varchar(20)
Unit of Sale (Uos) are available.
rosswalk.asp
PatlentLanguage
varchar(25)
Recipient's Language
The city component of the
Red ientAddressCity
varchar(50)
recipient's address
The county component of the
Reci ientAddressCoun
Int
recipient's address
The state component of the
Red ientAddressState
varchar(2)
recipient's address
The street component of the
RecipientAddressStreet
varchar(50)
recipient's address
The steet 2 component of the
RecipientAddressStreet2
varchar(SO)
recipient's address
The zip code of the recipient's
address (5 digit or 10 digits, with
RecipientAddressZipCode
int
hyphen, are aqx
TLable)
Reci lentDateOfBirth
date
Recipient's date of birth
2135-2 (Hispanic or Latino)
2186-5 (Not Hispanic or Latino)
UNK (Unknown ethnidty)
RecipIentEthnIcItV
varchar(10)
The ancestry of the patient
POL (Unable to report to do policy/law)
Unique ID for this recipient. This
can be the ID used by your
system or a randomly assigned
unique identifier. However, the
ID must be consistent across
reports to allow linking doses to
Reci ientid
int
the same recipient ID.
ReciplentNameFirst
varcha SO)
Recipient's first name
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RecipientNameLast
varchar(100)
Recipient's last name
RecipientNameMiddle
varchar(50)
Red lent's middle name
1002-5 (American Indian or Alaska Native)
2029-9 (Asian)
2076-8 (Native Hawaiian or Other Pacific Islander)
2054-5 (Black or African American)
2106-3 (White)
2131-1(Other Race)
UNK(Unknown)
POL (Unable to report due to policy/law)
RecipientRacel
varchar(10)
Patient's race
Patients race. Fields recipient
race 2-6 support recipients with
See Value Set in "RecipientRace V field
more than i race. (Skip if only
RecipientRace2
varchar(10)
one race reported).
Patient's race. Fields recipient
race 2-6 support recipients with
See Value Set in "RecipientRace 1" field
more than i race. (Skip if only
Reci IentRace3
varchar(10)
one race reported).
Patient's race. Fields recipient
race 2-6 support recipients with
See Value Set in "RecipientRace V field
more than 1 race. (Skip if only
ReciplentRace4
varchar(10)
one race reported).
Patient's race. Fields recipient
race 2-6 support recipients with
See Value Set in "RecipientRace 1" field
more than 1 race. (Skip if only
RecipientRace5
varchar(10)
one race reported).
Patient's race. Fields recipient
See Value Set in "RecipientRace 1" field
race 2-6 support redpients with
more than 1 race. (Skip if only
RecipientRace6
varchar(10)
one race reported).
M (Male)
F (Female)
U (Unknown/undifferentiated)
Reci ientSex
varchar(3)
Recipient sex
The name of the parent
organization or health system
that originated and is
accountable for the content of
the record. If an organization
has several clinics or facilities,
this would be the organization
that represents all of the
clinics/fadiities. (The
"Administered at location" field
is the name of individual
ResponsibleOrganization
varchar(50)
physical location.)
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The vaccination events unique
Identifier within the system.
This should be a unique
identifier for each vaccination
VaccinationEventld
varcha 50)
event.
Yes - Vaccination was refused
VAccinationRefusal
varchar(2)
Vaccination was refused.
No - Vaccine was administered
Yes - Series is complete
Report if the vaccination series
No - More doses are required
VAccinatlonSer-esComplete
varchar(S)
is complete.
UNK - Unknown or cannot be calculated
IT (Left thigh)
LA (left arm)
LD (left deltoid)
LG (left gluteus medius)
LVL (left vastus lateralis)
LLFA (left lower forearm)
RT (right thigh)
RA (right arm)
RD (right deltoid)
RG (right gluteus medius)
RVL (right vastus lateralis)
The body site of vaccine
RLFA (right lower forearm)
VacdneAdministedn a
varchad6)
administration.
The expiration date of the
VaccineExpirationDate
date
vaccine administered.
C38238 (Intraderrnal)
C28161 (Intramuscular)
C38284 (Nasal)
C38276 (Intravenous)
C38288 (Oral)
C38676 (Percutaneous)
The route of vaccine
C38299 (Subcutaneous)
VacdneRouteofAdministrat
administration (e.g., oral,
C3g305 (Transderrnal)
Ion
varcha 10
subcutaneous
This is the 6-ftit Provider PIN in
VrrckS. For VFC providers, this is
the VFC PIN. This ID is being
used for linking across data
sources.
If the event is reported as
historical, assign the PIN of the
VTrckSProviderPiN
varchar(13)
reporting entity.
Flag to identify recipients who
have multiple records with
differing
RecipientAddressCounty or
LHIChan a
varchar(i)
AdministrationAddressCoun
i - Different counties between records
Washington Disease Reporting
WDRS PAT ID
varchar(SO)
System ID
SerologyDrawDate
(Not available right away)
Date
Date specimen was collected
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COVID Vaccine Data
56=5ARS-CoV-2 V qualitative
57=SARS-CoV-2 RdRp gene result
58--SARS-CoV-2 result
58=overall SARS-CoV-2 result
60=SARS-CoV-2 N gene result
61=SARS-related CoV result
SerologyTypeCode
62=SAR5-CoV-2 ORFlab region result
(Not available right away)
Type of test performed
63=SARS-CoV-2 Ab qualitative
i=Positive
2=Negative
3dmmune
4--Non-Immune
S=Reactive
6=Non-reactive
SerologyResultld
7=Indeterminate
(Not available fight away)
Result of test
9--Intermediate
CENSUS TRACT'
Census tract used in geocoding
Not available r' ht away)
INT
for recipient's address
GEOCODE_X'
X coordinate used in geocoding
(Not available right away)
INT
for recipients address
GEOCODE_Y*
Y coordinate used in geocoding
Not available right away)
INT
for recipients address
PAT DEATH DATE
Nat available right away)
DATE
Patient date of death
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r
615 Sheridan Street
Port Townsend, WA 98368
�efeuon www.JeffersonCountyPublicHealth.org
66* Consent Agenda
JEFFERSON COUNTY
BOARD OF COUNTY COMMISSIONERS }
AGENDA REQUEST
TO: Board of County Commissioners
Mark McCauley, County Administrator
FROM: Apple Martine, Jefferson County Public Health Director
Denise Banker, Community Health Division Director
DATE: December 19, 2022
SUBJECT: Agenda item — Data Sharing Agreement, WA DOH; January 1, 2023 — December
31, 2024
STATEMENT OF ISSUE:
Jefferson County Public Health, Community Health Division, requests Board approval of Data Sharing
Agreement between WA Department of Health (DOH) and Jefferson County Public Health. DOH contract
number 19-JEF-COVIDVax-0, January 1, 2023 — December 31, 2024
ANALYSIS/STRATEGIC GOALS/PRO'S and COWS:
The purpose of this agreement is public health surveillance as it allows for a public health authority to
identify, monitor, assess, or investigate potential public health signals, onsets of disease outbreaks, or
conditions of public health importance. DOH will provide patient level COVID-19 vaccine administration level
data from the WA State Immunization Information System (WAIIS). Data will include doses administered to
Jefferson County residents as well as doses administered within Jefferson County facilities. Additionally, linked
COVID-19 case surveillance data (listed in variable list in Appendix E) will be included when these data
become available. r
FISCAL IMPACT/COST BENEFIT ANALYSIS:
There is no charge for this service. There is no fiscal impact.
RECOMMENDATION:
JCPH management requests approval of Data Sharing Agreement between WA Department of Health (DOH)
and Jefferson County Public Health. DOH contract number 19-JEF-COVIDVax-0, January 1, 2023 — December
31, 2024
;741f) I W.'14�1-3'E
Mark McCaule ounty Administrator Date
Community Health Environmental Public Health
Developmental Disabilities 360-385-9444
360-385-9400 (f)360-379-4487
360-385-9401 (f) Always working for a safer and healthier community
N-22-059
CONTRACT REVIEW FORM Clear Form
(INSTRUCTIONS ARE ON THE NEXT PAGE)
CONTRACT WITH: Dept of Health Contract No: N-22-059
Contract For: Data Sharing - COVID Vaccine Term: 1/1/2023 - 12/31/2024
COUNTY DEPARTMENT: Public Health
Contact Person: Denise Banker
Contact Phone: x 438
Contact email: dbanker&o )efferson.wa.us
AMOUNT: - 0 - PROCESS:
Revenue:
Expenditure:
Matching Funds Required:
Sources(s) of Matching Funds
Fund #
Munis Org/Obj
Exempt from Bid Process
Cooperative Purchase
Competitive Sealed Bid
Small Works Roster
Vendor List Bid
RFP or RFQ
Other:
APPROVAL STEPS:
STEP 1: DEPARTMENT CERTIFIES P CE 3.55.080 AND CHAPTER 42.23 RCW.
■
CO
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CERTIFIED: N/A: . Dec. 1, 2022
Signature Date
STEP 2: DEPARTMENT CERTIFIES THE PERSON PROPOSED FOR CONTRACTING WITH THE
COUNTY (CONTRACTOR) HAS NOT BEEN DEBARRED BY ANY FEDERAL, STATE, OR LOCAL
AGENCY.
CERTIFIED: El N/A: ❑� Dec. 1, 2022
ignature Date
STEP 3: RISK MANAGEMENT REVIEW (will be added electronically through Laserfiche):
Electronically approved by Risk Management on 12/7/2022.
State language.
STEP 4: PROSECUTING ATTORNEY REVIEW (will be added electronically through LaserFche):
Electronically approved as to form by PAO on 12/13/2022.
State language - cannot change.
STEP 5: DEPARTMENT MAKES REVISIONS & RESUBMITS TO RISK MANAGEMENT AND
PROSECUTING ATTORNEY(IF REQUIRED).
STEP 6: CONTRACTOR SIGNS
STEP 7: SUBMIT TO BOCC FOR APPROVAL