Data Request for External Researchers

Requestor Name

Please enter your Full name

Department

Please enter your Department

Requestor Email

Please enter your Email address

Site

Please enter your Site

Priority

Request Type

Date Required

Please select a required date

Short Description or Existing Report Name (Max 150)

What decision are you trying to make with this data?

How would you like the data displayed?

Scope of Data Start

Please select a date

Scope of Data End

Please select a date

Data fields/Criteria

Output Form

Contains Patient Protected or Confidential Information

After submitting this application, please email your IRB approval, HIPAA waiver and data collection spreadsheet.

Medical/Dental Staff