The code block below illustrates how one might use # and // as comments in your logic and calculations.

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The value you provided must be within the suggested range

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Required format:

4vFYSPyRgyiYqx2juUHkWrmQ3hRbVDHwPAfQBXdg4azYifd5fsgY8hY8rt9ff7bAYCru8Bh9W

Data Broker Request Form

Returning?

A A A

Please complete this form if you intend to use/disclose protected health information (PHI) in your research. PHI is health information transmitted or maintained in any form or medium that: identifies or could be used to identify an individual; is created or received by a healthcare provider, health plan, employer, or healthcare clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare to an individual.

Date Request Form was submitted.

M-D-Y

Project Title

Last Name
(Authorizing Person/Principal Investigator)

First Name
(Authorizing Person/Principal Investigator)

Affiliation

* must provide value

TUHS

TFPP

LKSOM

FCCC

TPI

TU (outside of TUHS)

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Person Completing this Form

* must provide value

Your Email address

Department/Division

Category of Request

* must provide value

1. Aggregate Data-Feasibility for Research

2. Aggregate Data-QA/PI

3. IRB Governed Research

4. QA/PI with Possible Future Research

5. QA/PI only

6. Other

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Project description.
What are your plans for using the data?
(Please be specific)

Expand

What are the specific inclusion and exclusion criteria required to select patients for analysis.
(ICD-10 codes if applicable, date range, sites)?

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Type of data you need

* must provide value

Aggregate Counts

Deidentified patient-level data

Fully Identified data

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What specific data do you expect to receive on the selected subjects? (eg MRN, demographics, labs, meds, etc.)

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If applicable to the request, We have found an upload of an Excel spreadsheet with sample columns and mock data greatly speeds up turn around time

Upload file

If non aggregate results, and multiple users:
Please upload an excel file with name, email, phone, affiliation, and nature of data usage (full or deidentified) of all others that will have access to delivered data.

Upload file

Does this project have IRB approval?

* must provide value

Yes

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IRB Protocol Number

Upload IRB protocol

* must provide value

Upload file

Upload IRB approval

* must provide value

Upload file

You indicate the work is preparatory to research. How will you decide that the preparatory work should transition to a formal research project?

* must provide value

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Check one of the following regarding the need to disclose data outside of Temple

* must provide value

Data will not be disclosed outside Temple - all data storage will be on TUHS hardware, and investigators/analysts are part of the TUHS Covered Entity

Data will be disclosed outside of Temple to a 3rd party Data Coordinating Center, registry and/or analyzed by an person or vendor outside of Temple

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Mechanism of electronic data storage

TUHS "U" Drive (the My Documents folder on a TUHS machine)

password-protected desktop computer on TUHS network

portable computer with whole-disk encryption

TUHS server

non TUHS server

Data Request/Query Stage

Initial Request

IRB Pending

Authorization Pending

Require Further Data Definitions

Require Further Explanation of Goals

Draft Query Complete

Final Query Complete

Project Completed-Additional Request Likely

Project Completed

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