Boston University Medical Campus
Clinical Research

Principal Investigator:

Email Address:

Phone Number:

IRB Protocol #:

Study Name:

Research Staff needing access to Protected Health Information:

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: