COVID-19 (Novel Coronavirus): Please click here for FAQs: Impact of COVID-19 on Human Subjects Research Data Request Form Clinical Data Warehouse (CDW) Services Please use this form to submit a CDW Data Request. If you are interested in speaking with CDW personnel about your study or request, email email@example.com and request a consultation.BMC CDW Updated Policies & Procedures April 2021: In a continuing effort to support the BUMC research community, the CDW has developed an updated Policies & Procedures Manual. The manual contains several revised policies, including: Timeline for Data Requests; Timelines for Data Delivery; and Billing & Invoicing. Research teams are encouraged to review the new CDW Policies and Procedures Manual here prior to submission of a CDW data request. If you need further clarification, please contact the CDW team. Thank you.Study InformationIRB Study Name or Project Title:*Project/Study Nickname:Has this study been submitted to the IRB for review?*Not yet submittedSubmitted - Review pendingApproved/determination madeNot applicableStudy IRB Protocol Number (H-#), if available:Study Principal Investigator:* First Last Degree(s) Principal Investigator's School or Institution*Select a school or institution from list:BUSMGSDMSPHGMSBMCOtherBUSM PI's DepartmentAdministration, BUSMAdmissions (MED)AlumniAnatomy & NeurobiologyAnesthesiologyBiochemistryCancer Research CenterClinical AffairsContinuing Medical EducationDermatologyDiversity and Multicultural AffairsEmergency MedicineFamily MedicineGeneral Clinical Research CenterGenome Science InstituteMedical EducationMedicineMedicine-Biomedical GeneticsMedicine-Cardiovascular MedicineMedicine-Clinical Epi Research & TrainingMedicine-Computational BiomedicineMedicine-Endocrinology, Diabetes & NutritionMedicine-GastroenterologyMedicine-General Internal MedicineMedicine-GeriatricsMedicine-Hematology & Medical OncologyMedicine-Infectious DiseaseMedicine-Molecular GeneticsMedicine-NephrologyMedicine-Preventive Medicine & EpidemiologyMedicine-Pulmonary, Allergy, Sleep & Critical CareMedicine-RheumatologyMedicine-Vascular BiologyMicrobiologyNational Emerging Infectious Disease LabNeurologyNeurosurgeryObstetrics & GynecologyObstetrics & Gynecology-General ObstetricsObstetrics & Gynecology-General GynecologyObstetrics & Gynecology-Gynecologic OncologyObstetrics & Gynecology-Maternal Fetal MedicineObstetrics & Gynecology-Reproductive EndocrinologyOffice of Academic AffairsOphthalmologyOrthopaedic SurgeryOtolaryngology-Head & Neck SurgeryPathology & Laboratory MedicinePediatricsPediatrics-Ambulatory Care ServicesPediatrics-Child DevelopmentPediatrics-Child NeurologyPediatrics-Clinical Affairs,Vice ChairPediatrics-Community PediatricsPediatrics-Critical CarePediatrics-Emergency MedicinePediatrics-General PediatricsPediatrics-GeneticsPediatrics-Infectious DiseasePediatrics-NeonatologyPediatrics-Other PediatricsPediatrics-Pediatric CardiologyPediatrics-Pediatric EndocrinologyPediatrics-Pediatric GastroenterologyPediatrics-Pediatric HematologyPediatrics-Pediatric NephrologyPediatrics-Pediatric Nutrition and FitnessPediatrics-Pediatric Pulmonary & AllergyPharmacology & Experimental TherapeuticsPhysiology & BiophysicsPsychiatryPulmonary CenterRadiation OncologyRadiologyRadiology-Body ImagingRadiology-Breast ImagingRadiology-Emergency RadiologyRadiology-Molecular Imaging & Nuclear MedicineRadiology-Musculoskeletal RadiologyRadiology-NeuroradiologyRadiology-Pediatric RadiologyRadiology-Vascular/Interventional RadiologyRehabilitation MedicineSlone Epidemiology CenterSociomedical SciencesStudent AffairsSurgerySurgery-Advanced Minimally Invasive SurgerySurgery-Cardiothoracic SurgerySurgery-Colorectal SurgerySurgery-Critical CareSurgery-Gastrointestinal SurgerySurgery-General SurgerySurgery-Other SurgerySurgery-Pediatric SurgerySurgery-Plastic SurgerySurgery-Podiatry SurgerySurgery-Surgical OncologySurgery-Transplant SurgerySurgery-Trauma SurgerySurgery-Vascular SurgeryWomen's Health Interdiscp Research CtrSPH PI's DepartmentBiostatisticsCenter for Health Law, Ethics & Human RightsCommunity Health SciencesEnvironmental HealthEpidemiologyGlobal HealthHealth Law, Policy & ManagementHealth Policy & ManagementGSDM PI's DepartmentEndodonticsGeneral DentistryHealth Policy & Health Svcs ResearchMolecular & Cell BiologyOral & Maxillofacial SurgeryOrthodontics & Dentofacial OrthopedicsPediatric DentistryPeriodontologyRestorative Sciences & BiomaterialsGMS PI's DepartmentBMC PI's DepartmentOther School or InstitutionCDW Request InformationPlease select the type of request:*Counts InformationRecruitment StudyRetrospective StudyOtherBrief description of your CDW request:*Selection Criteria: Define inclusion criteria and exclusion criteria (if applicable) for the study cohort. If IRB-approved study: Inclusion/exclusion criteria should match IRB-approved criteria or be a subset of IRB-approved criteria.Please enter selection criteria here:*Dates of requested records. If IRB-approved study: Dates should match IRB-approved dates or be a subset of IRB-approved dates.Please enter dates of requested records (from mm/dd/yyyy to mm/dd/yyyy) here:*Data Fields:List all data fields you are requesting from the CDW. List only the data fields you need the CDW team to pull for you. You do not need to include any data that you will hand abstract. If you are unsure about what information to include in your request, please email firstname.lastname@example.org to set up a quick consultation. If IRB-approved study: Requested data fields should match IRB-approved data or be a subset of IRB-approved data. Requested data fields may also be emailed as a Word document or Excel file to email@example.com. Reference the H-# in the email subject line. If emailing data fields, provide a summary of the requested data fields in the box below. Please enter data fields here:*Are you requesting a one-time extraction of data from CDW or multiple over time?*One-time extractionMultiple over timeIf you are requesting multiple extractions over time, please describe your plan.*Contact InformationWill the Principal Investigator be the primary contact working with CDW personnel for this request?*YesNoPrincipal Investigator's Email:* Principal Investigator's Phone:*Who is the primary contact who will be working with CDW personnel for this request?* First Last Degree Primary Contact's Email* Primary Contact's Phone:*Primary contact's title/role on this study (e.g., manager, coordinator, analyst, student, resident, fellow, etc.)*Is this project led by a trainee (a student, resident, or fellow)?NoYes, student-ledYes, resident-ledYes, fellow-ledTrainee Name* First Last Trainee's Mentor* First Last Funding InformationWhich grants office do you typically use, or, if you are a student or trainee, which does your PI/mentor typically use?*Select grants office from listBU-CRCBUMCBMCPlease indicate the type of funding source for this CDW project.*Extramural fundsInternal (i.e. Department or Division funds)No fundingPlease provide the name of the administrative contact for questions regarding payment.* First Last Administrative contact's email address 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 This iframe contains the logic required to handle Ajax powered Gravity Forms.