JPS Health Network External Data Request Form REQUEST DATE: JPS TICKET #: REQUESTOR IDENTIFICATION AND CONTACT INFORMATION SECTION JPS or Acclaim Staff UNT or TCU Faculty, Staff, or External to JPS (contractor, vendor, non-UNT or -TCU ○ ○ ○ Student researcher, etc.) DATA NEEDS SECTION PHI IS NEEDED. LIMITED DATA SET IS NEEDED. DE-IDENTIFIED DATA IS NEEDED (following HIPAA ○ ○ ○ regulations). DATA USE SECTION TPO * USE CLINICAL RESEARCH USE: DSRIP/1115 Waiver OTHER (PLEASE EXPLAIN): ○ ○ ○ ○ MARKETING USE JPS IRB number: Project: ○ FUND RAISING USE JPS IRB approval date: ○ GOVT/PUBLIC HEALTH Please attach approval letter, ○ REQUIRED REPORTING protocol and data collection form Limited Data Use Agreement currently in place (if so, please attach copy) ○ DISCLOSURE INTENT SECTION HOW DO YOU PLAN TO USE THIS DATA? JPS or Acclaim etc. CLINICIANS EXTERNAL TO JPS PUBLIC PRESENTATION OR PUBLICATION ○ ○ ○ (Attach Limited Use Data Agreement) VENDOR OR BUSINESS RESEARCHERS FROM OTHER GOVT. OR PUBLIC AGENCY ○ ○ ○ PARTNER INSTITUTIONS TO BE COMPLETED BY REQUESTOR NAME: TITLE: ORGANIZATION: ADDRESS: ZIP: OFFICE CELL: EMAIL: CONTACT IF NOT SAME AS ABOVE NAME: TITLE: ORGANIZATION: ADDRESS: ZIP: OFFICE PHONE: CELL: EMAIL: PURPOSE OF REQUEST: * TPO: Treatment, Payment and Healthcare Operations
JPS Health Network External Data Request Form REQUEST DATE: JPS TICKET #: REQUESTOR IDENTIFICATION AND CONTACT INFORMATION SECTION ○ JPS or Acclaim Staff ○ UNT or TCU Faculty, Staff, or Student ○ External to JPS (contractor, vendor, non-UNT or -TCU researcher, etc.) DATA NEEDS SECTION ○ PHI IS NEEDED. ○ LIMITED DATA SET IS NEEDED. ○ DE-IDENTIFIED DATA IS NEEDED (following HIPAA regulations). DATA USE SECTION ○ TPO * USE ○ MARKETING USE ○ FUND RAISING USE ○ GOVT/PUBLIC HEALTH REQUIRED REPORTING ○ CLINICAL RESEARCH USE: JPS IRB number: JPS IRB approval date: Please attach approval letter, protocol and data collection form ○ DSRIP/1115 Waiver Project: ○ OTHER (PLEASE EXPLAIN): ○ Limited Data Use Agreement currently in place (if so, please attach copy) DISCLOSURE INTENT SECTION HOW DO YOU PLAN TO USE THIS DATA? ○ JPS or Acclaim etc. ○ CLINICIANS EXTERNAL TO JPS ○ PUBLIC PRESENTATION OR PUBLICATION (Attach Limited Use Data Agreement) ○ VENDOR OR BUSINESS PARTNER ○ RESEARCHERS FROM OTHER INSTITUTIONS ○ GOVT. OR PUBLIC AGENCY TO BE COMPLETED BY REQUESTOR NAME: TITLE: ORGANIZATION: ADDRESS: ZIP: OFFICE CELL: EMAIL: CONTACT IF NOT SAME AS ABOVE NAME: TITLE: ORGANIZATION: ADDRESS: ZIP: OFFICE PHONE: CELL: EMAIL: PURPOSE OF REQUEST: * TPO: Treatment, Payment and Healthcare Operations
edgc_data_request_form_083116.docx