mcit clinical research reporting data request form 1 ann arbor, mi ...

MCIT CLINICAL RESEARCH REPORTING DATA REQUEST FORM
4251 PLYMOUTH ROAD, SUITE 2200
ARBOR LAKES BUILDING 2, FLOOR 2
ANN ARBOR, MI 48105-3640
FAX: 734.615.0571
REMEDY: BIR-CRHIX
REQUEST DATE:
TKT/CSR#:
REQUESTOR IS UMHS FACULTY,
STAFF, STUDENT, VOLUNTEER OR
TRAINEE.
REQUESTOR IDENTIFICATION AND CONTACT INFORMATION SECTION
REQUESTOR IS UM FACULTY, STAFF, REQUESTOR IS EXTERNAL TO UM (CONTRACTOR,
STUDENT, VOLUNTEER OR TRAINEE.
VENDOR, NON-UM RESEARCHER, ETC.)
DATA NEEDS SECTION
PHI IS NEEDED. LIMITED DATA SET IS NEEDED. DE-IDENTIFIED DATA IS NEEDED.
TPO USES
MARKETING USES
FUND RAISING USES
GOVT/PUBLIC HEALTH REQUIRED
REPORTING
DATA USE SECTION
CLINIC RESEARCH USES
IRB #: ____________
PRIVACY BOARD #: ___________
OTHER (PLEASE EXPLAIN):
WHAT INFORMATION IS TO BE SHARED EXTERNALLY:
DISCLOSURE INTENT SECTION
UM CAMPUS FACULTY, STAFF,
STUDENTS, ETC.
VENDOR OR BUSINESS PARTNER
CLINICIANS EXTERNAL TO UMHS
RESEARCHERS FROM OTHER
INSTITUTIONS
PUBLIC PRESENTATION OR PUBLICATION
GOVT. OR PUBLIC AGENCY
TO BE COMPLETED BY REQUESTOR
NAME: ______________________________________ UM TITLE: ________________DEPARTMENT:
CAMPUS ADDRESS: _____________________________________________________ZIP/BOX:
PHONE: PAGER: EMAIL:
CONTACT IF NOT SAME AS ABOVE
NAME: ______________________________________ UM TITLE: ________________DEPARTMENT:
CAMPUS ADDRESS: _____________________________________________________ZIP/BOX:
PHONE: PAGER: EMAIL:
PURPOSE OF REQUEST:
NOTE: WHEN REQUESTING PHI OR NON-SUMMARIZED PATIENT LEVEL DATA FOR RESEARCH PURPOSES, REQUESTOR MUST HAVE OBTAINED IRB OR PRIVACY
BOARD APPROVAL PRIOR TO SUBMITTING REQUEST. PLEASE ATTACH A COPY OF THE APPROVAL OR AUTHORIZATION WHEN SUBMITTING THIS REQUEST.
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MCIT CLINICAL RESEARCH REPORTING DATA REQUEST FORM
STATEMENT OF UNDERSTANDING/DATA USE AGREEMENT:
DATA OBTAINED FROM THE REPORTING TEAM MAY BE USED ONLY FOR THE PURPOSES STATED IN THIS APPLICATION AND ITS ACCOMPANYING IRB
APPROVAL (IF REQUIRED). PATIENT CONTACT INFORMATION PROVIDED BY THE REPORTING TEAM MUST NOT BE RETAINED FOR USE IN ANOTHER
STUDY. THE PRINCIPAL INVESTIGATOR / REQUESTER OF THIS REQUEST IS RESPONSIBLE FOR ANY MISUSE OF THESE DATA.
I ALSO UNDERSTAND THAT IN ACCORDANCE WITH THE HOSPITAL'S POLICY ON THE CONFIDENTIALITY OF PATIENT CARE INFORMATION,
ANY INAPPROPRIATE DISSEMINATION OF INFORMATION MAY RESULT IN DISCIPLINARY ACTION. I AGREE TO ABIDE BY THESE STATEMENTS.
REQUESTER'S SIGNATURE TITLE DR. # DATE
AUTHORIZED* SIGNATURE TITLE DR. # DATE
*IF YOU ARE NOT AN ATTENDING STAFF PHYSICIAN, DEPARTMENT DIRECTOR/HEAD OR PRINCIPAL INVESTIGATOR, YOU WILL NEED AN AUTHORIZED SIGNER.
DATA SOURCE:
HEALTH SYSTEM DATA WAREHOUSE CDR EWS MIS
SEARCH CRITERIA:
PATIENTS: INPATIENT OUTPATIENT ER
TIME FRAME: ADMISSION DATE SERVICE BEGIN DATE
DISCHARGED DATE
SERVICE END DATE
PROCEDURE DATE
OTHER: __________________________________
DATE OF BIRTH
DEMOGRAPHICS: AGE MARITAL STATUS
SEX
RELIGION
RACE
PRIMARY LANGUAGE
OTHER: __________________________________
HOSPITAL INFO: PATIENT TYPE ADMIT TYPE
LENGTH OF STAY
ADMIT SOURCE
ADMITTED PAVILION
FINANCIAL CLASS
DISCHARGED PAVILION
DISCHARGED STATUS
DIAGNOSES:
MSDRG:
PROCEDURES: DOCTORS: DR. #
ATTENDING
PROCEDURE
ADMIT
DISCHARGED
MAJOR
REFERRING
SERVICES: ADMIT SERVICES/FLOORS:
DISCHARGED
ALL
NOTE: WHEN REQUESTING PHI OR NON-SUMMARIZED PATIENT LEVEL DATA FOR RESEARCH PURPOSES, REQUESTOR MUCH HAVE OBTAINED IRB OR PRIVACY
BOARD APPROVAL PRIOR TO SUBMITTING REQUEST. PLEASE ATTACH A COPY OF THE APPROVAL OR AUTHORIZATION WHEN SUBMITTING THIS REQUEST.
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MCIT CLINICAL RESEARCH REPORTING DATA REQUEST FORM
SPECIFY OTHER CRITERIA:
FIELDS NEEDED:
REGISTRATION NUMBER
ADMIT DIAGNOSES
SERVICES
ADMISSION/VISIT DATE
DISCHARGED DIAGNOSES
FLOORS
DISCHARGED DATE
PROCEDURES
DOCTORS
DATE OF BIRTH
MSDRG
CHARGES
AGE
FINANCIAL CLASS (EX. MEDICARE, MEDICAID, COMMERCIAL)
ADMIT TYPE (ER, OUTPATIENT, NEWBORN, SCHEDULED)
RACE
ADMIT SOURCE (ER, HOME, CLINIC, OTHER HOSPITAL, ETC.)
ADMIT PAVILION (MOTT, WOMEN’S, UH/KELLOGG, PSYCH, OUTPATIENT)
PRIMARY LANGUAGE
LENGTH OF STAY
DISCHARGED PAVILION (MOTT, WOMEN’S, UH/KELLOGG, PSYCH, OUTPATIENT) SEX
OTHER:
OUTPUT FORMAT: HARDCOPY
FILE (PLEASE SPECIFY FORMAT: _____________________________)
‣ SEND THROUGH EMAIL
‣ SHARED DIRECTORY
‣ PICK UP
DELIVERY SCHEDULE: ONE TIME ONLY ROUTINE DAILY ROUTINE WEEKLY (SPECIFY DAY OF WEEK _________)
ROUTINE MONTHLY ROUTINE QUARTERLY ROUTINE ANNUALLY (PLEASE CIRCLE)
‣ FISCAL (JUL-JUN)
‣ CALENDAR (JAN-DEC)
SPECIFY RUN DATE FOR ROUTINE REPORT: ______________________________
IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT A MEMBER OF THE REPORTING AND ANALYTICS TEAM:
LYNN HOLEVINSKI PLYNN@MED.UMICH.EDU 734.647.9186
SHIRLEY FAN SHIRLFAN@MED.UMICH.EDU 734.936.2475
NOTE: WHEN REQUESTING PHI OR NON-SUMMARIZED PATIENT LEVEL DATA FOR RESEARCH PURPOSES, REQUESTOR MUST HAVE OBTAINED IRB OR PRIVARCY
BOARD APPROVAL PRIOR TO SUBMITTING REQUEST. PLEASE ATTACH A COPY OF THE APPROVAL OR AUTHORIZATION WHEN SUBMITTING THIS REQUEST.
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