I have completed a System Access Request
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Yes
No
If you have access to i2b2 or TriNetX then the answer is yes!
Point of Contact First Name
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Point of Contact Last Name
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Point of Contact Email:
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Team member email address:
Team member email address:
Team member email address:
Team member email address:
Team member email address:
Study title (for tracking purposes)
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Which of the following best describes the funding status of your project?
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Funded Funding Pending Unfunded
Which is (or is anticipated to be) the primary source of funding for this project?
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CTSA May's Cancer Center Barshop Institute PepperCenter Extramural Grant (specify granting agency and type of grant) Industry Funded I am working on finding a source of funding for my project Stats for Students Pediatrics Fellowship KL2 Scholar Other (please specify)
If you selected Other for the primary source of funding please specify:
Agency (NCI, NIA, AHRQ, etc) and grant type (R01, R21, K01, etc):
Type of study:
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Retrospective Study Clinical Trial QA Preparatory for Grant (query building) Other
If you selected Other for the type of study please specify:
Has this project been submitted via the
CTO Portal and completed review by CTO?
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Yes
No
Not Required
Do you have the CRI De-identified Data Warehouse, UHS Sunrise EHR or EPIC EHR listed as a data source in your IRB paperwork?
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Yes
No
We will request a copy of your protocol prior to creating the statement of work
What type of data will you be requesting?
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Deidentified (dates shifted, no identifiers)
Limited data set (e.g. real dates, but everything else deidentified)
Identified (Need identifiers E.g. MRN, Names, Addresses)
Aggregate (query building)
What identifiers that you listed in form J or equivalent will you be requesting from CRI?
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Please make sure that these are listed in your Form J otherwise you will need to revise your IRB paperwork
What identifiers that you listed in form J or equivalent will you be requesting from CRI?
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Please make sure that these are listed in your Form J otherwise you will need to revise your IRB paperwork
If you selected Other for the identifiers please specify:
By checking off the box and submitting this form, the data recipient attests to the following:
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IRB Protocol Number:
(Note: If available)
The number assigned to your project by IRB should be copy-pasted into here from the IRB approval letter or IRB determination letter that you will be uploading below. A project for which a determination of non-research or determination of non human-subjects research is made is still considered an IRB protocol.
Is there a deadline for receiving this data?
Yes
No
What is the deadline?
Note: There is a minimum 10 business day turnaround time from the submission date of the project request form.
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Today M-D-Y
Please sign here:
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Todays Date:
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Today M-D-Y
What was the date of consultation
Today M-D-Y
How did the consultation go?
Terrible Bad Ok Good Great
Date the Statement of Work was sent to the researcher
Today M-D-Y
Date the Statement of Work was received from the researcher
Today M-D-Y
What data sources did the researcher want to pull from?
Please elaborate on what data are we providing the researcher with (especially if 'Custom' is selected above)?
Date the data was provided
Today M-D-Y
Today M-D-Y
Today M-D-Y
Closing comments and lessons learned:
Is this project archived?
Yes No
Today M-D-Y
Reason for being archived
Completed No response from researcher Researcher pulled out Unable to provide required data until X Absolutely unable to provide data Other
What is the researcher waiting for
UTMed data refresh UHS data refresh New data source Hardware upgrade Other
Please elaborate why we cannot provide the data, new data source, etc
How would you rate interacting with the researcher?
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