Data Request Form

Please provide the following information about your request Please select the type(s) of your request:*

Counts Information
Recruitment Study
Retrospective Study
Other

Brief 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 request

Will you be the main person working with the Clinical Data Warehouse Personnel for the request*

Yes
No

Main person's name*

First Last

Main person's role in this study*

Please provide main person's title or role if "Other"*

Main person's email address*

Main person's phone*

Main person's School*

Please 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)

PI Information

Is the PI of the study the same as the main person working with the CDW for the data request (identified above)?*

Yes
No

PI Name*

First Last

PI Type*

PI's Degree*

PI's Faculty Rank (if applicable)*

PI's Email*

PI's Phone*

PI's School*

Does the PI have an eRA Commons name?*

PI'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 Information

Has this study been submitted to the IRB for review?*

Study IRB Protocol Number (H-#)*

IRB Classification*

The 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 number

Which grants office do you typically use, or if you are a student or trainee, which does your mentor typically use?

BUMC or BMC grant/account number

Are funds available to pay for this data analysis project?*

If funds are available to pay, please indicate funding source:*

If you chose "Other" as funding source, please specify.*

Name of administrative contact to arrange payment*

First Last

Administrative contact's email address*

Student/Trainee Research

Is 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).*

If you answered No, skip to section 6.

Is the student/trainee the same person as the PI identified in Section 3?*

Yes
No

Student/Trainee Name*

First Last

Faculty Advisor Name*

First Last

Type of student/trainee*

Trainee's School*

Please enter Trainee's school if you selected Other*

Research is required by*

If 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

Clinical Data Warehouse Services Request

Contact information for the person who will be working with CDW for this data request

PI Information

Study Information

Student/Trainee Research