COVID-19 (Novel Coronavirus): Please click here for FAQs: Impact of COVID-19 on Human Subjects Research Data Request Form Clinical Data Warehouse Services Request Please provide the following information about your request Please select the type(s) of your request:*Counts InformationRecruitment StudyRetrospective StudyOtherBrief description of your request:*Selection Criteria (e.g., asthmatics seen in Asthma Clinic)Dates of required records (from mm/dd/yyyy to mm/dd/yyyy)Data fields required (list the fields required from the electronic database)Contact information for the person who will be working with CDW for this data requestWill you be the main person working with the Clinical Data Warehouse Personnel for the request*YesNoMain person's name* First Last Main person's role in this study*Select a role from list:Coordinator/ManagerPIPI/BMC FellowPI/BMC ResidentPI/StudentFellowPost-docResidentScholarStudent/DoctoralStudent/DentalStudent/Master'sStudent/MedicalStudent/PharmacyStudent/OtherOtherPlease provide main person's title or role if "Other"*Main person's email address* Main person's phone*Main person's School*Select a school from list:MEDGSDMSPHGMSOtherPlease enter main person's School if you selected Other*If you have provided the information below for previous CDW requests, you may skip to question 3.Main person's degree(s)Main person's faculty rank (if applicable)Select a rank from list:InstructorAssistant ProfessorAssociate ProfessorProfessorResearch InstructorResearch Assistant ProfessorResearch Associate ProfessorResearch ProfessorNonePI InformationIs the PI of the study the same as the main person working with the CDW for the data request (identified above)?*YesNoPI Name* First Last PI Type*Select a role from list:Coordinator/ManagerPIPI/BMC FellowPI/BMC ResidentPI/StudentFellowPost-docResidentScholarStudent/DoctoralStudent/DentalStudent/Master'sStudent/MedicalStudent/PharmacyStudent/OtherOtherPI's Degree*PI's Faculty Rank (if applicable)*Select a rank from list:InstructorAssistant ProfessorAssociate ProfessorProfessorResearch InstructorResearch Assistant ProfessorResearch Associate ProfessorResearch ProfessorNonePI's Email* PI's Phone*PI's School*Select a school from list:MEDGSDMSPHGMSOtherDoes the PI have an eRA Commons name?*Select from list:YesNoPI's NIH eRA Commons name*The PI's NIH eRA Commons ID is necessary for the CRRO to obtain credit for the consultation to support the CTSI grant. The eRA Commons ID is given by NIH to principal investigators at institutions/organizations to access and share administrative information relating to research grants. If the PI does not have an eRA Commons ID, he/she must obtain one to ensure proper credit for this consultation. If the PI is a BUMC or CRC investigator, please visit (http://www.bu.edu/rosa/sponsor-system-access/). If the PI is a Boston Medical Center investigator, please contact the BMC Grants Administration office through (grants.admin@bmc.org) with the following information: --Full name --Email address. --eRA Commons Role (Postdoc, PI, Trainee, etc.) For more information, see http://ctsi.bu.edu/index.php/contact-us/ Study InformationHas this study been submitted to the IRB for review?*YesNoStudy IRB Protocol Number (H-#)*IRB Classification*Select classification from listExemptExpeditedExpedited: Limited Data SetFull BoardOtherThe Privacy Rule (45 CFR 164.512) allows the use or disclosure of protected health information required in order to prepare a research application or proposal, provided that certain criteria are met. Please read the following statements. If you agree, please enter your name below. The use or disclosure requested will be limited to the preparation of a research protocol or for similar purposes preparatory to research. No protected health information will be removed from the covered entity by the researcher in the course of the review. The requested information constitutes the minimum necessary data to accomplish the goals of the research. By submitting this Clinical Data Warehouse service request, the PI attests to the following: I declare that the requested information constitutes the minimum necessary data to accomplish the goals of the research. I agree that the protected health information will not be re-used or disclosed to any other person or entity, except as required by law, for the authorized oversight of the research study, or for other research for which the use or disclosure of protected health information would be permitted by the Privacy Regulation (45 CFR 164.512)Attestor's Name:*Study name/Project title (if applicable)For funded projects, please indicate funder here.Funder grant or project numberWhich grants office do you typically use, or if you are a student or trainee, which does your mentor typically use?Select grants office from list:BU-CRCBUMCBMCOtherN/ABUMC or BMC grant/account numberAre funds available to pay for this data analysis project?*YesNoIf funds are available to pay, please indicate funding source:*Select grants office from list:Boston University accountBoston Medical Center accountOtherIf you chose "Other" as funding source, please specify.*Name of administrative contact to arrange payment* First Last Administrative contact's email address* Student/Trainee ResearchIs the study that will be the subject of this data request be student/trainee research? That is, the study is being conducted to provide research experience or to satisfy a program requirement for a student or trainee (includes residents and fellows).*YesNoIf you answered No, skip to section 6.Is the student/trainee the same person as the PI identified in Section 3?*YesNoStudent/Trainee Name* First Last Faculty Advisor Name* First Last Type of student/trainee*Select student/trainee type from list:BMC FellowBMC ResidentFellow/OtherResident/OtherStudent/MedicalStudent/DentalStudent/SPHStudent/DoctoralStudent/MastersStudent/PharmacyStudent/OtherTrainee's School*Select school from list:MEDGSDMSPHGMSCRCOtherPlease enter Trainee's school if you selected Other*Research is required by*Training programSpecific courseResearch not requiredIf research is required by a training program, please describe*If research is required by a specific course, what is the course number?*If this is your first time requesting data from the CDW, please let us know how you heard about this service.I'm not a robot