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. Note: Please do not to include PHI in this data request form. The staff member that is completing this data request will connect with the requester and ask for this information at a later time. Thank you.

Q2. Requester(s):*

Q3. Contact information for follow-ups regarding this data request (Full name and email address):

Q4. Request date:*

Q5. Project name:*

Q6. Faculty PI/Project Director name:*

Q7. Is the PI's primary faculty appointment in Family Medicine?

Yes
No

Q8.

If this is an externally funded project, please provide the chartstring and funding information here.

Q9.

Are you requesting a fee waiver for this data extraction service? If so, please select from the list below.

This is a FM funded pilot project
This is an unfunded FM QI project
Other

Q39. Is this a Center for Integrative Medicine/Krupp Project?

Yes
No
Not Sure

Q10. Does this project require an IRB approval or is this a QI (quality improvement) project?*

Requires IRB approval
Is a QI project
Other

Q11. IRB status:*

Q12. IRB number (if available):

Q13. Is the IRB Research Plan on file?*

Yes
No
Not applicable

Q14. Do you have an IRB approval letter?*

Yes
No
Not applicable

Q15. DFM Research Executive Committee Approval (if no IRB approval):

Q16. Completion date (by when do you need this data?)*

Q17. Enter any key project deadlines (e.g. report to funders, abstract submission deadline, conference presentation) here.

Q18. Will patient data be sent to any entity outside of UCSD?

Q19. Description of Research Plan (Briefly, what are the research questions? How will you be using the data?)*

Q20. Inclusion Criteria: Include ICD/billing codes if known, medication names, relevant date windows etc.*

Q21. Exclusion Criteria: Include ICD/billing codes if known, medication names, relevant date windows etc.*

Q22. Data elements needed (data items you want to see on the final report). For example, demographics, diagnoses, procedures/CPT codes, labs, medications, vitals, other.*

Q23. Data date range:*

Q24. Geographic coverage:

Q25. Aggregation level:

Q26. Number of patients (estimate):

Q27. Protected patient categories (eg. minors, prison inmates):

Q29. Patient identifiers (check all that apply)

Q30. Data sources/systems:

Q31. Data will reside in:

Q32. Who needs access to the data?*

Q33. Does your data request specifically require Renu, or Kevin, for assistance?

Renu
Kevin
Not sure/either

Q34. If applicable, please upload a copy of your most recent IRB approval letter here.

Q35. If applicable, please upload a copy of your most recent IRB research plan here.

Q36. Notes/Comments: