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If you experience any challenges viewing or navigating this form (like Maximize form screen) , you can open the survey in a new REDCap window by navigating to https://redcap.link/RDS_FEASrequest, or by clicking the highlighted link.

Feasibility counts request form

Let us help you obtain population counts for hypothesis generation and grant applications. Feasibilities are provided free of charge to IU, Purdue, and Notre Dame investigators. For other researchers, a quote for the requested services will be provided after the evaluation of your request.

ABOUT THIS FORM: This form should be used when requesting only aggregate counts to support a grant/funding proposal, hypothesis generation, or similar research purpose.

Counts will be provided in aggregate format
Counts less than 10 will be listed as < 10
Data may come from the Indiana Network of Patient Care, IUHealth's Cerner data warehouse, and/or Eskenazi's Epic data warehouse
DO NOT send Protected Health Information (ePHI) using this form

If you need a dataset, MRN list, or other results that are not aggregate counts, please use our Data Request Form instead.

If you need an informal estimate or formal quote for the project to accompany your grant submission, please ALSO submit a request using our Quote Request Form.

PLEASE NOTE: The information provided via a feasibility request is for preliminary counts, for research purposes only, and should not be used for publications or presentations unless express permission is received from Regenstrief Institute.

Principal Investigator

First Name
Last Name
Email Address

Investigator Profession

* must provide value

Investigator's Profession: Other

Investigator's School/Affiliation

* must provide value

Eskenazi Health Department

Administration

Other

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Eskenazi Health Department Other

Fairbanks School of Public Health Department

Fairbanks School of Public Health Department Other

Indiana CTSI Department

Indiana CTSI Department Other

IU Health Department

Administration

Other

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IU Health Department Other

IU School of Dentistry Department

IU School of Dentistry Department Other

IU School of Health Department

IU School of Health Department Other

IU School of Informatics Department

IU School of Informatics Department Other

IU School of Medicine Department

IU School of Medicine Department Other

IU School of Nursing Department

Undergraduate

Graduate

Other

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IU School of Nursing Department Other

IU School of Optometry Department

Undergraduate

Graduate

Other

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IU School of Optometry Department Other

IU School Public and Environmental Affairs Department

IU School Public and Environmental Affairs Department Other

Other IU Campus, School, and Department

* must provide value

Purdue University Department

Regenstrief Institute Department

Regenstrief Institute Department Other

University of Notre Dame Department

Company/Organization if other than those listed above

Company/Organization Department

Does your project team currently include an investigator affiliated with Indiana University, the Regenstrief Institute, and/or Indiana CTSI?

* must provide value

Yes

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Please note: since you are not currently working with an IU, Regenstrief Institute, or Indiana CTSI partner, we will follow up shortly with a quote for this work.

If you are seeking a Regenstrief or IU investigator to collaborate with on your project, please email: workwith@regenstrief.org.

Please provide the name and affiliation of your partnering investigator at IU, the Regenstrief Institute, and/or Indiana CTSI.

* must provide value

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Please provide the email address of your partnering investigator.

* must provide value

Team members and contact information

Role	Name	Email address
Co-Investigator
Project Coordinator, Manager, or Contact Person

Other email address(es) to be included in correspondence, separated by semicolons (up to 3 email addresses):

Study Title / Project Name

* must provide value

Did you run a query in i2b2 related to this feasibility request? (Click here to learn more about i2b2.)

Yes

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How is the requested information being used?

How is this information being used? Other - please describe

What type of Biobank request is this?

Banked

Prospective

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Which institutions should we query for you? (select one or more)

* must provide value

Eskenazi Health

IU Health

All INPC

Specific institutions not listed above (opens text box)

Which institutions should we query for you? (provide list)

Please provide a high level description of your request:

* must provide value

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What is your research question?

* must provide value

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What types of aggregate counts are you requesting? Please also describe any related summary counts that would be helpful. Provide as much detail as possible, including specific ICD 9/10 codes, care settings, and date ranges whenever possible. (Alternatively, attach a document below that outlines the counts needed.)

PLEASE NOTE: the analyst assigned to your request will be unable to begin work without this information.
Examples:
1. "We need to know the number of individuals who were seen in the ER for eye trauma between 2020 and 2023; we will provide ICD codes for eye trauma."
2. "Please provide a count of IUH patients 2019-2021 who had an ICD-9/ICD-10 code for relapsed multiple myeloma (203.02, 203.12, 203.82; C90.02, C90.12, C90.22). We are also requesting a count of how many of these patients have one or more clinical notes available in the year after that diagnosis."

* must provide value

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Cohort Inclusion Criteria:
Example: all female patients with a visit with an ICD-9 code of 780.3x and/or 345.x whose age is greater than 50 and less than or less than or equal to 75.

* must provide value

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Cohort Exclusion Criteria:

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Cohort Size Estimate (if known):

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Start Date for the above cohort:

Data availability: INPC data begins in 2005. There is some amount of data for Eskenazi (formerly Wishard Hospital) going back to around 1993, and we can also directly query the G3 data warehouse for Wishard data (ends Oct 2016); please include a note to us if you are interested in having us search prior to 2005.

End Date for the above cohort:

Have you worked with the Data Core before for feasibility counts or a data pull?

* must provide value

Yes

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I would like to schedule an introductory meeting to learn more about data sources and Data Core services

Yes

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Is there a date/deadline by which you need to receive this data?

Please note that we may not be able to accommodate all deadline requests.

* must provide value

Yes

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Please provide the date by which you need to receive data from RDS in order to meet your project timeline and/or internal grant submission deadline.

* must provide value

M-D-Y

Is there any other information we should know? (e.g., details regarding an urgent deadline)

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Would you like to provide any attachments?

NOTE: Individual patient identifiable data should be sent via Secure Share. This form is NOT HIPAA-aligned and should not be used for protected health information.

Yes

Attachment 1

Attachment 2

Attachment 3

Attachment 4

Attachment 5

Jira email

Date of submission

M-D-Y

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