IDR Request Form FacebookThis field is for validation purposes and should be left unchanged.Initial 2 hours of data services are provided at no charge. Additional analyst time will be billed at $130/hr. New requests are reviewed once weekly. The assigned analyst will reach out to you within 8 days of request submission. For questions about data request submissions or other IDR research request questions, please contact: IRBDataRequest@ahc.ufl.edu Select Request Type (choose one) Data Self-Service Discovery Tool Registration (i2b2, ATLAS, Cosmos) IRB-approved Research Data Request Consent2Share (C2S) Recruitment Non-Human (fully de-identified) Data Request Consultation/Prep To Research Data Self-Service Discovery Tool Registration(Required) i2b2 Registration ATLAS (OMOP CDM) Registration Epic Cosmos Portal i2b2 Instances(Required)Select one or more of the following. You will receive an email once request has been completed. UF Health Gainesville UF Health Jacksonville OneFlorida+ NCATS ACT IMPORTANT NOTE: Before submitting this request, you must login to ATLAS using your Gatorlink account: https://omop.rc.ufhealth.org/atlas/#/home PLEASE NOTE: UF Health has a limited number of Cosmos user accounts. Each request requires UF Health IT Leadership approvalUsers must have an Epic Hyperdrive login and Epic Userweb account for Cosmos access. DO NOT include any patient specific information (e.g. real MRNs) in the form.Epic Username (login)(Required)This is the username you use to login to Epic Hyperdrive Epic UserWeb Name(Required)UserWeb name can be found by clicking on your profile on Epic Userweb (userweb.epic.com) UserName (UF GatorLink of UF Health Username)(Required)Please only use your UF GatorLink or UF Health Username. DO NOT include email domain (@ufl.edu, @ufhealth.org, or @shands.ufl.edu) **DO NOT make up a username**Username domain(Required) Gatorlink UF Health IRB-approved Research Data Request(Required) MRN only Detailed (Line-Level) Data Elements Images Only NOTE: Use this selection only if requesting data per a NonHuman Determination form or for Cancer or Covid OMOP datasets. If requesting de-identified data per an approved IRB, please use the IRB-approved Research Data Request option above and indicate that you want de-identified data. Data Elements (de-identified)(Required) Custom IDR prepared de-identified data set(s) OMOP Domain Specific Data sets (Cancer & Covid) OMOP De-Identified Data Sets(Required)Select the type of fully de-identified OMOP data set. OMOP Cancer Dataset OMOP Covid-19 Dataset If you need an image for immediate clinical care decision making, please contact Marcia McGriff (rodrmj@radiology.ufl.edu) and Naomi Oldham (Oldham@shands.ufl.edu)Must have local IRB, WCGIRB (WIRB), or Exempt Auto-Determination tool to receive C2S patient list. Per C2S rules, only patient name and approved and requested contact information may be provided by the IDR for a C2S data release. If requested limited demographic data (age, sex, and race) may also be provided.Requestor or Point of Contact Name(Required)Enter name of individual the research data team should contact for questions and clarifications. First Last Requestor or Point of Contact Email(Required) Role(Required)SelectFacultyStaffResidentPostdoctoral fellowGraduate StudentUndergraduate StudentOtherSelect the choice that most closely describes your request for images(Required) The IDR will identify patients and images for retrospective study The study team will identify patients and provide patient information to the imaging team PI Full Name(Required) First Last PI Email Address(Required) College/Department(Required)Financial contact name(Required)Name of individual IDR research data services team should contact with questions about billing First Last Financial contact Email Address(Required) IRB Number(Required)The IRB number has one of the following formats: IRB202000123, CED202000123, WCGIRB202000123IRB Title(Required)IRB Protocol(Required)Upload a copy of your approved IRB and other related documents here. Drop files here or Select files Accepted file types: pdf, xlsx, docx, Max. file size: 125 MB. Project Number(Required)Enter IRB, WCG/WIRB, or Exempt Determination Tool #Attach protocol(Required)Upload IRB or WCG/WIRB protocol or Exempt Determination Tool email confirmation Drop files here or Select files Max. file size: 125 MB. IRB Expiration Date(Required) MM slash DD slash YYYY Non-human requests must have completed the Non-human auto-determination tool. Please include copy of auto-determination email and signed Confidentiality Agreement. This is the same Confidentiality Agreement submitted as part of the Non-Human auto-determination form. You may upload completed forms using the fields below.Non-human determination number(Required)The # is found in the email notification when Nonhuman determination tool was submitted. It starts with “NHxxxxxxxx””Upload Non-human determination email confirmation(Required)Accepted file types: pdf, xlsx, docx, Max. file size: 125 MB. Upload Signed Confidentiality Agreement (CA)(Required)Accepted file types: pdf, xlsx, docx, Max. file size: 125 MB. Project Title(Required)Cosmos Project Description(Required)Provide details on type of project you wish to complete and how you plan to use Cosmos. Please note that general Cosmos portal access provides data as counts (in aggregate) that you interact with using Epic's SlicerDicer tools. Access to fully de-identified line-level data requires completion of Epic's Cosmos for Data Scientists course.Project Description(Required)Please attempt to create cohort in self-discovery tools i2b2 or ATLAS.(Required)Creation of your cohort using these tools will improve request turn around time and associated costs. Has cohort been created in i2b2 or ATLAS first? Yes - please enter query name in field below. No / Not Applicable i2b2 or ATLAS Query Name(Required)Please create cohort in i2b2 or ATLAS first and include query name in field.Inclusion Criteria(Required)Please be specific. Provide specific ICD codes if targeting specific disease states and CPT codes if targeting select procedures. Exclusion CriteriaPlease be specific. Provide specific ICD codes if targeting specific disease states and CPT codes if targeting select procedures. Data Elements(Required) Custom IDR prepared data set(s) All OMOP data (click to expand for list of all OMOP data tables) All OMOP data plus additional non-OMOP data elements Select the type of de-identified data elements you wish to receive(Required)NOTE: All data will be fully de-identified and dates shifted. Custom list of data elements All OMOP data (click to expand for list of all OMOP data tables) All OMOP data plus additional non-OMOP structured data elements Data Elements - Images(Required) View OMOP common data model tables (PDF) LIST ONLY THOSE DATA ELEMENTS YOU WISH THE IDR RESEARCH DATA SERVICE TEAM TO PULL. DO NOT include data elements you plan to manually collect through chart review or other mechanisms. Requested data elements must be listed in your approved IRB. LIST ONLY THOSE DATA ELEMENTS YOU WISH THE IDR RESEARCH DATA SERVICE TEAM TO PULL. NOTE: unstructured de-identified data (e.g. notes, images, etc) may not be provisioned under a Non-human determination form. These require IRB approval. Enter data elements you wish the IDR to pull. Do not include PHI (e.g. real patient MRNs) in this form.(Required)C2S Patient contact Info(Required) Name Email Telephone# Mailing address (only if material to be mailed to patient) Which UF Health campus are these data to be pulled from?(Required)Select all that apply. Gainesville Jacksonville Central Florida Health St. Johns Other Other(Required)Questions for the IDR Research Data Team(Required)Confidentiality Agreement: De-identified data set(Required)Terms of Use Terms of Use Access to UF Health Open Access De-identified Research Datasets (“Datasets”) is restricted to members of the University of Florida (“UF”) and UF Health community and is permitted solely for research purposes. Users are strictly prohibited from attempting to re-identify, or facilitating the re-identification of, any individual represented within the Datasets. All Datasets must be stored exclusively on password-protected, encrypted servers that comply with UF and UF Health information security standards. The Datasets may not be shared, distributed, or otherwise disclosed outside of UF or UF Health without prior written authorization. Any request to share the Datasets externally must be directed to the UF Office of Sponsored Research for review and, if approved, must be governed by a duly executed Data Use Agreement. For questions regarding transfers of data outside UF, please visit https://privacy.ufl.edu/bulk-sensitive-data/ or contact at bulk-sensitive-data@ufl.edu. Publications and other research outputs derived from the Datasets must report only aggregate-level results. Publications must also acknowledge support from the University of Florida Clinical and Translational Science Award (CTSA) and the UF Health Integrated Data Repository (IDR) team. By accessing or using the Datasets, you agree to comply with these terms and all applicable UF, UF Health, and federal regulations. I confirm that I have read and understand this Confidentiality Agreement (Required) I agree not to share these data outside of the UF/UF Health organization.
