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Privacy and Ethical Review Policy


Privacy, Ethical Review, System Security and Database Management Policy Statement...

It is CORI’s policy to control the collection, use, and disclosure of personal information in accordance with requirements set out in the Freedom of Information and Protection of Privacy Act of Alberta and other relevant provinces, as well as, the Personal Information Protection and Electronic Documents Act of Canada. In the case that CORI must comply to new legislation or additional legislation from other jurisdictions, CORI will make a commitment to do so in a timely manner, as is reasonably possible. The Board of CORI reserves the right to make changes to these policies in the cases where CORI needs to improve adherence to legislation, adhere to new legislation, or to provide quality service.

Part A: CORI Privacy Policy Statement

Part B: Ethical Review Policy

Part C: System Security & Database Management Policy



Part A: CORI Privacy Policy Statement

1. Accountability
The CORI is responsible for personal information under its control and designates the Executive Director to be accountable for the CORI's compliance with the Acts.

2. Identifying Purposes
The purposes for which personal information is collected shall be identified by the CORI at or before the time the information is collected.

3. Consent
The knowledge and consent of agency directors and individuals are required for the collection, use, or disclosure of personal information.

4. Limiting Collection
The collection of personal information shall be limited to that which is necessary for the purposes identified by the agency for case management, outcome management, and administrative data collection that would normally occur in the day-to-day work of agency personnel. CORI will not demand any additional data collection for any research, best practice, or other evaluation projects. All associate agencies have the right to decline involvement in collection of data for evaluation of CORI service’s.

5. Limiting Use, Disclosure and Retention
Personal information shall not be used or disclosed for purposes other than those for which it was collected, except with the consent of the individual or as permitted by law. Personal information shall be retained only as long as necessary for the fulfillment of those purposes or where stated by law. CORI will not use, disclose, or retain information for corporate interest. In the case that CORI uses information to investigate best practices of services within specific client or community problem and need areas, only aggregated data will be reported. All analyses of such data must comply to the policies and procedures of the CORI Ethics Procedures and Policies (based upon the “Tri-Council Policy Statement for Ethical Research with Humans”).

6. Accuracy 
Agency personnel are responsible to be as accurate, complete, and up-to-date as is possible and necessary. CORI will not edit any agency information unless directed to do so by the agency user.

7. Safeguards 
CORI will protect Personal information using security safeguards such as encryption coding, firewalls, hierarchical security login models, and other technology where appropriate to protect the confidentiality of information.

8. Openness
The CORI shall make readily available to individuals specific information about its policies and practices relating to the management of personal information.

9. Individual Access
Upon request, an individual shall be informed of the existence, use, and disclosure of his or her personal information and shall be given access to that information. An individual shall be able to challenge the accuracy and completeness of the information and have it amended as appropriate. In the case that clients request such information, the agency collecting data will be informed and a joint agency. Client, and CORI meeting can be established to fully disclose any personal information available on the CORI system. 

10. Challenging Compliance
An individual may challenge compliance with the above principles to the Executive Director of CORI or individuals accountable for the CORI's compliance. 

11. CORI Responsibility
Compliance. All CORI employees, who collect, maintain and/or use personal information, are responsible for insuring that the collection, use and disclosure of this information is carried out in accordance with this policy and relevant procedures. 

Noncompliance. CORI employee noncompliance to the above policies or CORI Ethical Procedures may result in the employees termination.

Accountability. The Executive Director is accountable for the CORI's policies and practices, management of the CORI System, and is the individual to whom complaints and inquiries can be forwarded.



Part B: Ethical Review Policy

Introduction
...
Prior to developing an application for ethic review, all investigators should become familiar with the CORI policy statements. Familiarization with the ethics review process and the parameters for conducting research will ensure that the process proceeds as smoothly as possible. The CORI has adopted the Tri-Council Policy statement on Ethical Conduct for Research Involving Humans to develop its policy statements, ethics review procedures, and to act as the basis for ethical decision-making (a copy can be accessed through: http://www.nserc.ca/programs/ethics/english/policy.htm ). 

Investigators must familiarize themselves with this document. Most requests to use CORI data for any research or evaluation must go through the Ethics Review Process prior to any data analyses. However, some exceptions do apply. For example, evaluation of a single agency and its programs with the informed consent of the agency, or when requested by the agency does not require an ethics review using the CORI Review Process. The ethics review also does not need to occur when more than one agency wishes to produce a joint evaluation of services. In such instances, all agencies must consent to evaluation and submit their own data sets to the evaluator.

Review Process
In all instances where evaluation or research is planned using multiple agency data and the analyses require complied data using the CORI database, then an ethics review is required.
In these cases, all applications to use CORI data for any research or evaluation must go through the Ethics Review Process prior to any data analyses (see the Ethics Committee Review Flow Chart and the CORI Ethics Review Application Form Introduction for specific procedures).

Purpose of Review
The purpose of the Ethics Review is to ensure that all research and evaluation using CORI data meet basic criteria for best practice research. It also ensures that both client and agency confidentiality and anonymity are protected and that there is a maximum of benefit to clients, agencies, regions, and the community while minimizing harm.

Review Committee Meetings
The ethics Review Committee or Research Ethics Board (REB) will meet 30 days or more after an application is forwarded to the CORI and one week or more after all members receive the application proposal. 

Committee Meeting Costs

All costs that are related to ethics committee meetings are the responsibility of the investigator that submits the proposal and/or his or her sponsoring organization.

Client Consent
Each Agency using the CORI or HOMES system must create its own consent form indicating that the client, as a part of service with the agency, consents to having information stored and retained by the Hull Outcome Monitoring and Evaluation System (HOMES). The agency will inform the client that stored information is for the purposes of project and service case management and for evaluation of the effectiveness of the services the client will receive. CORI data is collected with the intent to determine the best practices within specific service areas or to assist human service professionals to better address specific client-related problems. In all cases, research or evaluation proposals must fit within this stated purpose.

In the case that a proposal requests that additional research or evaluation be completed with client sets, then agencies must approve such requests prior to submission, and all clients and/or guardians must sign an additional consent form stating the purpose of the research or evaluation. In addition, relevant regional authorities must be contacted and prior approval be given within each region to consent to the proposed research or evaluation.

Releases of Data
All releases of data must be for case management, program management or program evaluation. Agency Executive Directors may release data from their own data sets for their own case management, program management or program evaluation purposes.

  • The ethics committee is convinced that the basis of the research or evaluation is to determine the best practices within a specific service area or to assist human service professionals to address specific client-related problems.
  • The ethics committee is convinced that the investigator can give assurances that the released analyses will not be used for purposes other than to advance knowledge regarding best practices within specific service areas or to assist human service professionals to address specific client-related problems.
  • The ethics committee is convinced that the risks associated to the proposal are clearly outlined and justified.
  • The ethics committee is convinced that the benefits to the clients, agencies, community, and/or regions are great enough to out weight any inherent risks in the proposal.
  • The analyses of data will be conducted at the CORI site.
  • The results of the data are compiled to ensure client and agency anonymity.
  • Only data analyses results are submitted to external researchers, not raw data.
Analyses Guidelines
All analyses will only occur after the Ethics Review Process has been conducted and the review process ends with approval and consent of the analyses. Only the data from regions that consent to the analyses will be used in the actual analyses. The following guidelines must all be met in the analyses:
  • The basis of the research or evaluation is to determine the best practices within specific service areas or to assist human service professionals to better address specific client-related problems.
  • Assurances be given that the released analyses will not be used for purposes other than to advance knowledge regarding best practices within specific service areas or to assist human service professionals to better address specific client-related problems. 
  • The proposal states that data analyses do not require identification of any clients.
  • The proposal states that data analyses do not require identification of any agencies.
  • The proposal states that data analyses do not require identification of any projects.
  • The data analyses uses sample sizes greater than 30.
  • The requested data analyses use samples from greater than 3 projects in each identified sector area.
  • The requested data analyses do not require a file transfer of any unaggregated CORI data to an external site. 
  • The researcher shall provide a copy of all reports generated using CORI data.
  • The CORI and the CORI HOMES system shall be acknowledged on all reports.
Decision-Making Criteria and Key Questions:
The ethics Review Committee or Research Ethics Board (REB) and will use the Tri-Council Policy Statement on the Ethical Conduct for Research Involving Human Research as the guiding document for ethical processes and decision making. 

The REB may decide it’s own decision making criteria based on specific proposals. However, such criteria must be rooted in the principles found within the Ethical Conduct for Research Involving Human Research. Some examples of additional criteria might include specific client issues, academic responsibilities, or legal considerations (see the Ethical Conduct for Research Involving Human Research for details). 

Proposals must demonstrate that minimal risk to clients, project/programs, agencies, communities, and regions would be created if the research or evaluation proposal were conducted. Other criteria should include practical considerations concerning the CORI and its data. With this in mind key questions have been developed to ensure that proposals are critically examined. Although the REB is not limited to these questions, some key questions REB members will be asked include:
  • Are you convinced that the basis of the research or evaluation is to determine the best practices within a specific service area or to assist human service professionals to address specific client-related problems?
  • Can assurances be given that this proposal will not be used for purposes other than to advance knowledge regarding best practices within specific service areas or to assist human service professionals to address specific client-related problems?
  • Are the risks associated to the proposal clearly outlined and justified?
  • Are you convinced that the benefits of the research and/or are great enough to out weight any minimal risks in the proposal?
Such key questions are hoped to ensure that the proposal is critically examined to ensure minimal risk to clients, agencies, communities, and/or regions.

Conflicts of Interest
Applicants will disclose any actual, perceived or potential conflicts of interest to the REB prior to the review of proposals.


Part C: System Security & Database Management Policy

Systems Developer Qualifications
The Canadian Outcomes Research Institute will only hire or contract with systems developers with a diploma or degree in a computer related field with training and/or experience in Internet architecture and development, and web page design using HTML, SQL, ASP, VB, JAVA, and JAVA Script computer languages. CORI will retain at least one full-time systems developer with security and database management as his or her major duties.

Security Awareness Training
All HOMES system developers must attend training sessions to become aware of the security risks and responsibilities for use of the HOMES. This includes the use of computer and database security ID’s and passwords, limits to this security model, the nature of the data contained within the HOMES, and a requirement to seek informed consent from clients. They are trained not to disclose or alter any information contained within the agency site database, not to disclose configuration of the hardware, not to disclose software or web page code for the HOMES system that may compromise security, and trained not to provide registration of users except when approved the Executive Director of CORI.

Database Backup Policy
The HOMES system and database is stored on multiple computers (server) and backed up daily on tapes. A rotating back-up cycle is used such that 5 tapes are rotated through a back-up cycle each week. In addition, four additional tapes back-up one day each week on a four-week rotating cycle. Two additional tapes are used to back-up data on a two week rotating cycle within each month (monthly tapes). The most recent completed back-up tapes are removed from the CORI site each day.

Continuity Planning, Disaster Recovery
The servers that contain the HOMES software and database must use hardware that mirrors the memory of the hard drive on alternate hard drives. This is to ensure that if one hard drive becomes damaged, then an alternate hard drive can be used as a backup. Backup tapes must be stored in a separate location and rotated among many tapes so that many backups provide assurance that data is not only difficult to loose, but also if it is lost a backup copy exists to ensure minimal loss of data entry. The monthly back-up tape must be stored in a separate location away from CORI at the fiscal agency’s site.

Location and Distribution of Information, Physical Security
The Internet server is located in CORI’s office in Calgary. The office must be locked and protected by an alarm system. The alarm system requires a personal ID to activate and deactivate. Default activation occurs after the office is vacated after a set period of time, no more than one minute. The back up tape location for monthly back-ups is at the main office of CORI’s fiscal agent. These tapes must be stored in a lock and alarmed location at the fiscal agent.

HOMES Security and System Design
Security and User Authentication. Access to the server occurs using a firewall, Secure Sockets Layer technology, encryption coding using a VerisignÔ Certificate, Active Server Page technology, Agency User ID and Passwords, and specific Personal User Authentication ID’s and passwords. Access to all data on the HOMES system must use all of these security features. In addition, database tables are not directly read so that knowledge about the construction of the database itself is not released to individuals or organizations external to CORI. 

Table Structure and Security. One table each is used to store identifying information on clients and staff. All other data is stored in reference tables and data record tables in a coded from. The database stores information related to clients and staff in coded characters and numerals so that merely reading a table without relating it to other specific tables makes reading a table a meaningless collection of numbers and characters.

Access. Agencies must have access to their data sets 24 hours per day, each day of the year, with the exception of those times that the CORI servers are not operational due to maintenance. Agencies must directly input data into the server from their own locations using Internet Explorer and their own Internet provider. CORI is not responsible for agency’s hardware, software, networks, Internet access, and not responsible regarding how to best establish this technology in the agency. Data must be into the data warehouse and filtered through a security model and Active Server Pages. Thus, agencies may only have access only to client data related to their own agency. Agencies use their own data for case management and outcome reporting requirements. Each agency has the capability to print any data contained within the HOMES database. Case and agency reports developed for the HOMES are based upon requests by the member agencies for specific information, reporting formats, and/or funding/regulatory bodies.

Data Storage
Data is stored using an SQL database connected to a web server. The SQL database must not have direct access to an Internet line. Only the Internet web server can have direct access to the internet line. CORI will retain data entered into the HOMES Database on CORI servers, and:
  • CORI servers must be separate from all of its associate agency operational servers,
  • The CORI server room must be locked at all times unless being services by a database administrator,
  • Back-ups to the server data must occur every business day and the back-up tapes are kept in a separate location,
  • The most recent monthly back-up tapes cannot be taken off the fiscal agent site.

    Access to CORI Servers
  • Access to CORI servers through the Internet can only occur using agency SSL ID’s and Passwords and using Personal ID and Passwords,
  • Associate Agency personnel will only have a maximum of Evaluation Group level access, no greater,
  • Associate Regional Agency personnel will only have a maximum of District level access, no greater,
  • Only the Database Administrators, CORI Executive Director, and Trainers will have the highest security level, Database Administrator Access,
  • Only the Database Administrators and CORI Executive Director have full access to the servers.

    Unauthorized Access to CORI Servers
  • Unauthorized access and hacking will be monitored each business day. The Executive Director of the CORI will be notified of all unauthorized accesses.
  • The IP address of persons who attempt unauthorized access will be documented and once identified, they will be immediately locked from use of the CORI servers.
  • In cases where any data was attempted to be downloaded and/or access was attempted to be restricted to users, then relevant authorities will be contacted and possible charges laid.
  • In cases where unauthorized access was suspected and the user was locked out, the user must contact the Director of the CORI to reinstate the user’s access to the CORI database. In all such cases, appropriate reasons for suspected unauthorized access must be given for the reinstatement to occur.


Microcomputing Controls

In addition to the above procedures, all development of the web pages and SQL design must be tested on developmental servers prior to upgrading web pages and SQL design on the public access servers. The developmental servers must not be connected to the CORI web servers and cannot leave the CORI office. 

Upgrades to software and hardware technology must occur at regular, minimally annual, intervals. However, depending on the nature of the software on the server, upgrades to the software may occur more regularly. Users must be given at least one week notice when a major upgrade to software code occurs or when the servers are shut down for maintenance purposes. 

Virus checking software must be upgraded every two business days. Servers must be cleaned of viruses on the same day as the software upgrade or more often depending on the types of viruses that are current. 

Database Architecture
Public release of HOMES architecture, code, and other proprietary information, such as server IP addresses, is prohibited by CORI staff unless approved by the Executive Director and CORI Board. Backup knowledge of the architecture and code of the CORI system must be retained by the fiscal agent of CORI.

The HOMES system includes use of an ISDN line, firewall, web server, SQL server, and a special application server (i.e. for spell checking or other applications). 

Web page development must use security filtering code to ensure that each agency may only add, view, and edit data specifically related to their accounts. Such code will be written using HTML, SQL, ASP, VB, JAVA, and JAVA Script computer languages.

CORI code and structure relating to the SQL database is broken into three components: data tables, reference tables, and stored procedures. Release of SQL code information, including when users view “source” code of the HTML Web pages, must not contain specific names of the data tables, reference tables, stored procedures, or other references to the system architecture.

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