Clinical Data Access Request Online Form

Clinical Research Data Request

Principal Investigator:

Degree(s):

Academic Title:

Email Address:

Phone Number:

Study Title/Study Idea:

IRB Protocol #:

Department:

Section:

eRA Commons ID # and/or Grant ID:

Boston University’s Clinical and Translational Science Institute (BU CTSI) will support some data requests that are for translational research and are not funded by a grant. Please consider the following questions if the research is not funded by a grant:

Will the requested data be applied to any of the following areas?
1) The transfer of new understandings of disease mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy, and prevention and their first testing in humans;
No
Yes

2) The translation of results from clinical studies into everyday clinical practice and health decision making;
No
Yes

3) The discovery of ways to move clinical findings into the daily care of patients;
No
Yes

4) The movement of scientific knowledge into the public sector and thereby changing people’s everyday lives.
No
Yes

If translational and unfunded, then CTSI will pay for the first 8 hours of work towards this data request.

How will you pay for the services?
Internal Boston University funds (via journal entry)
Boston Medical Center funds
Evans Medical Foundation funds
Other

Please supply the email address to which the bill for the Clinical Data Warehouse services ($60/hour) should be sent? Note that there is no charge for requests that take less than 1 hour.

Data and/or Records Needed for Research Protocol: Include the following information
as it applies to your study. Please verify that data you are requesting is covered
by your HIPAA and/or IRB forms:

1. Source of Data (e.g., Logician, SDK, etc.) if known:

2. Selection Criteria (e.g., all patients with a visit with an ICD-9 780.3x and/or 345.x,
English speakers whose age > 50 and age <= 75, etc.)

3. Counts (if applicable): (e.g., number of patients seen by Firm A, B, C grouped by
under 65 and 65 or older)

4. Dates of Records: (e.g., January 1, 2004 – March 31, 2005)

5. Number of Records: (e.g., 2000 patients with specified diagnosis, 10% sample of
patients with diagnosis, all patients admitted thru ED)

6. List of Data Fields:(e.g., age, race, diagnosis, service area, PCP, etc.)

7. Desired Format of Data: (e.g., Excel, Word, etc.)

8. Comments:

Primary teaching affiliate
of BU School of Medicine