Data request form Note: Submissions will be triaged between analysts within the Regenstrief Data Core and IUHealth.
This form asks for IRB and funding information - if not yet known, these items can be supplied later; however, please be aware that work will not begin until funding details have been received.
If you have not yet received a quote for the effort required for your project, and would like to receive it prior to filling out this request, please submit a quote request here and we will be happy to assist you.
(Looking for preliminary/feasibility counts? Click here to use our feasibility request form.) Note: This form is not HIPAA-aligned and should not be used for protected health information , either in the form or as an attachment. Individual patient identifiable data should be sent via Secure Share.
Principal Investigator First Name
* must provide value
Principal Investigator Last Name
* must provide value
Principal Investigator Email Address
* must provide value
Company/ Organization Name
* must provide value
Eskenazi Health Fairbanks School of Public Health Indiana CTSI IU Health IU School of Dentistry IU School of Health and Rehabilitation Sciences IU School of Informatics and Computing IU School of Medicine IU School of Nursing IU School of Optometry IU School Public and Environmental Affairs Purdue University Regenstrief Institute University of Notre Dame Other
Eskenazi Health Department
Administration Other
Eskenazi Health Department Other
Fairbanks School of Public Health Department
Epidemiology Social and Behavioral Sciences Health Policy and Management Environmental Health Biostatistics Other
Fairbanks School of Public Health Department Other
Project Development Team Clinical Research Center Indiana Biobank Research Recruitment Office Other
Indiana CTSI Department Other
Administration Other
IU Health Department Other
IU School of Dentistry Department
Biomedical and Applied Sciences Cardiology, Operative Dentistry, and Dental Public Health Endodontics Oral Pathology, Medicine, and Radiology Oral Surgery and Hospital Dentistry Orthodontics and Oral Facial Genetics Pediatric Dentistry Periodontics and Allied Dental Programs Restorative dentistry Other
IU School of Dentistry Department Other
IU School of Health Department
Health Sciences Nutrition and Dietetics Occupational Therapy Physical Therapy Physician Assistant Other
IU School of Health Department Other
IU School of Informatics Department
Computer Science and Informatics Information and Library Science Intelligent Systems Engineering Other
IU School of Informatics Department Other
IU School of Medicine Department
Anatomy and Cell Biology Anesthesia Biochemical and Molecular Biology Biostatistics Cellular and Integrative Physiology Dermatology Emergency Medicine Family Medicine Medical and Molecular Genetics Medical Libraries Medicine Microbiology and Immunology Neurological Surgery Neurology Obstetrics and Gynecology Ophthalmology Orthopedic Surgery Otolaryngology - Head and Neck Surgery Pathology and Laboratory Medicine Pediatrics Pharmacology and Toxicology Physical Medicine and Health Reahabilitation Psychiatry Radiation Oncology Radiology and Imaging Services Surgery Urology Graduate Division Other
IU School of Medicine Department Other
IU School of Nursing Department
Undergraduate Graduate Other
IU School of Nursing Department Other
IU School of Optometry Department
Undergraduate Graduate Other
IU School of Optometry Department Other
IU School Public and Environmental Affairs Department
Public Affairs Healthcare Policy and Management Arts Management Environmental Sciences Environmental Sustainability Studies Other
IU School Public and Environmental Affairs Department Other
Purdue University Department
Regenstrief Institute Department
Center for Aging Research Center for Biomedical Informatics Center for Health Services Research Industry Research Office Other
Regenstrief Institute Department Other
University of Notre Dame Department
Company/Organization if other than those listed above
Company/Organization Department
Co-Investigator Email Address
Project Manager Name
* must provide value
Project Manager Phone Number
* must provide value
Project Manager Email Address
* must provide value
Business Manager Name
* must provide value
Business Manager Phone Number
Additional contact email addresses
(Provide up to 3, separated by commas)
Please select the best description for your study/request:Please note: An recruitment or chart review list may ONLY contain the variables MRN, DOB, race, and gender . If you require more data points in your request, please select one of the recruitment options, or data extraction.
* must provide value
Recruitment for interventional study
Recruitment for observational study
Recruitment or chart review list (ONLY includes variables MRN, DOB, race, and gender)
Data extraction
Registry
Precision Health Initiative (PHI)
Other
Are you recruiting from IU Health?
* must provide value
Yes
No
Is anyone on the study team employed as a clinician at IU Health?
* must provide value
Yes
No
Please provide the name of the IU Health clinician.
* must provide value
In order to obtain IU Health data for recruitment purposes, a person authorized to recruit for IU Health will need to be a member of the study team. To be connected with someone who can fulfill this role, please contact Brenda Hudson, Indiana Clinical and Translational Sciences Recruitment Concierge Director at brlhudso@iu.edu.
You are requesting a recruitment list. Have you been in contact with ResNet regarding recruitment?
Yes
No
Data Request from PHI DSTs:
ORIEN
Multiple Myeloma
Ped PST
Clinical
Genomic
Both
Vendor providing sequenced genomic data:
Nantomics
FMI
DNA Nexus
Ashion
CMG
Tempus
Generated genomic data file type:
DASTQ
Annoations
Bams
VCF
RNA seq.
mRNA seq
Do you need to provide any data (e.g. established cohort list) to the data analyst? If yes, an analyst will reach out to arrange transfer. Please note that 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 .
* must provide value
Yes
No
What type of data do you plan to request?De-identified data may contain offset dates or year, no geography smaller than US state.
Limited data allows real dates and geographic levels city, state and zip code.
Identified data may contain protected health information (e.g. MRNs, names, DOB, address). Not sure? Contact AskRDS@regenstrief.org and we will be happy to help you determine which data type best fits your research needs.
* must provide value
Deidentified Data Set Limited Data Set Protected Health Information (e-PHI) Not Sure
Where do you plan to store the data?
Please note: data will need to be stored in an approved location, and this location will be listed on data agreements for identified and limited data.
Common approved locations include Secure Microsoft Teams, REDCap, Carbonate, Regenstrief server, IU Department of Biostatistics server. Please let us know if you need assistance with this decision.
* must provide value
Secure Microsoft Teams (previously Box Health) REDCap Carbonate Regenstrief Server IU Department of Biostatistics Server Other
Where will you be storing the data?
Other
Do you plan to submit this data to an organization outside of your own?
* must provide value
Yes
No
If submitting this data to another organization, please provide the name of that organization:
Please explain how you would like your population defined.
* must provide value
Start Date for the above cohort
Today M-D-Y 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
Today M-D-Y
Do you know which health systems you would like to get data from?
* must provide value
Yes
No
Are you requesting IU Health data only?
* must provide value
Yes
No
Do you need real-time IU Health data?
("Real time" refers to a continuous feed of data, and does not include recruitment lists.)
* must provide value
Yes
No
Note: IU Health fulfills all requests for real-time data. By selecting this option, your request will be forwarded directly to IU Health.
Do you need IU Health billing data?
(Refers to billing/cost data. Does not include using ICD codes to identify or supplement patient cohorts.)
* must provide value
Yes
No
Note: IU Health fulfills all requests for billing data. By selecting this option, your request will be forwarded directly to IU Health.
I would like to schedule an introductory meeting to learn more about data sources and Data Core services
Yes
No
Are you new to working with EHR/HIE data and interested in consultation with a medical/informatics expert at CTSI to help guide your data request?
Yes
No
Regenstrief Data Services (RDS) has a Clinical Research Data Officer (CRDO) available to assist on data extractions, thanks to support from Indiana CTSI. The CRDO is available to work alongside you and the RDS data analyst to develop data requirements, provide clinical insight, and ensure data quality. Would you like to have the CRDO's participation in this project?
Yes
No
Project/protocol title
* must provide value
IB protocol # and project title
* must provide value
Please provide a lay description / summary of your project
* must provide value
Do you have IRB approval?
Please note that current IRB documents must be provided before data can be released. These documents include the Protocol Questionnaire, Protocol Summary, and approval letter(s) or notification that the study is not human subjects from each applicable IRB. You will have an opportunity to upload IRB documents on the last page of this request if you have them available at this time.
* must provide value
Yes-submitted and approved Yes-submitted and pending No-I plan to submit No-Not Applicable
What is the current funding status?
Please note work will not be assigned until funding has been established.
* must provide value
Funded Planned Unfunded
Who is the funder? (Please indicate name of company/organization):
What is the funding source type?
Federal/State Non-Federal Department/Discretionary Commercial Other
Have you been communicating with anyone at Regenstrief regarding funding?
* must provide value
Yes
No
Please provide the name of your contact
Yes
No
When was the quote request submitted? An approximate date is acceptable.
Please submit a quote request at regenstrief.org/rds/quote/ as soon as possible, unless this work falls under a previous estimate or quote, or a member of the RDS team has given other instructions.
Have you completed a data request before?
* must provide value
Yes
No
Do you recall who you worked with?
Is there a hard deadline by which you would like to receive the requested data?
* must provide value
Yes
No
Today M-D-Y
Is there any other information you would like to include?
Is there an outside company/commercial entity involved in your project? It includes sharing data, IP, code, other.
Yes
No
Please provide the name of the company/commercial entity.
* must provide value
Who owns the IP coming out of this project?
Does sponsor own the data after delivery?
Yes
No
Please submit sponsor contract with rest of the documentation.
Please submit sponsor contract with rest of the documentation.
Who (name, company) will receive the data requested for this project?
Do you have any attachments? PLEASE 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
No
Today M-D-Y
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