Data Request Form

(*) denotes required field
Requester Name:(*)
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Requester Email:(*)
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Requester Phone:(*)
Please use this format xxx-xxx-xxxx

Requester Blazer ID:(*)
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Requester Role:(*)
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Principal Investigator (PI):(*)
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PI Email:(*)
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PI Blazer ID:(*)
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Name and Blazer ID for people with whom data will be shared:
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School / Center / Institute:(*)
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Department:(*)
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Division (if applicable):
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Study/IRB Title:
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IRB Number:
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ClinicalTrials.gov ID:
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Funding Source (if applicable):
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This is a...?(*)

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Title of previous data report:(*)
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Has your query been run in i2b2 before?
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If you checked "Yes" above, please list the name of the query and date:
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Data needed for:(*)

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If you checked "Other" above, please explain here:
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What type of data set do you need?(*)

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Did you know you can access aggregated data via the CCTS self-service i2b2 tool?
Please define your study population: (e.g. African American women over 50 years old with type 2 diabetes, white males diagnosed with myocardial infection in past 60 days.)(*)
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What data do you want on your study population? Click here to see a list of searchable variables.(*)
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What time frame should your data cover? (e.g. past 3 months, 2011-2016)(*)
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Do you want results organized by demographics (e.g. age, race, ethnicity, gender), time (e.g. month, year), or other variable?(*)
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Does your research address the following (select all that apply):(*)

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