IDR Request Form Request Type*The initial 2 hours of services are provided at no charge, following that, the hourly rate of $130/hr for analyst time applies. For more information regarding our research services please visit: https://idr.ufhealth.org/research-services/ OMOP: ATLAS registration (summary statistics only, fully de-identified) OMOP: Line-level Data Elements based on ATLAS query (fully de-identified) OMOP: Prebuilt, Domain-specific Datasets (fully de-identified) Consultation i2b2 Registration Preparatory Research/Cohort Discovery IRB-Approved Consent2Share IRB-Approved MRN ONLY IRB-Approved Line-level Data Elements IRB-Approved IT Build IRB-Approved Images (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) Nonhuman with confidentiality agreement Select the choice that most closely describes your request for images* The IDR will identify patients and images for prospective/recruitment study The IDR will identify patients and images for retrospective study The study team will recruit patients and provide information for images The study team will provide information for images for retrospective study i2b2 Instances*Please select one or all of the following options to initiate your i2b2 Account. You will be contacted via email once your provisioning has been completed. UFHealth Gainesville UFHealth Jacksonville OneFlorida NCATS ACT UserName (UF GatorLink, Shands or UMC JAX Username)*Please use your UF GatorLink, Shands or UMC JAX Username. This is the ID you most commonly use to Sign On to your network. DO NOT make up a username. We ONLY use domain authentication. (e.g. Albert Gator's email address is agator@ufl.edu but Albert's username is agator) Username domain*Select the domain of your username.Select domainGatorlinkShandsUMC JAXRequestor Name*ATLAS access to de-identified data in HiPerGator for counts/cohort discovery. NOTE: Before submitting request, you must login to ATLAS using your Gatorlink account. This step is required to initiate access. https://omop.rc.ufhealth.org/atlas/#/home First Last Requestor Name* First Last Requestor Email*This is an internally restricted service, please use username@ufl.edu (GatorLink) or username@shands.ufl.edu (Shands) email addresses only. Enter Email Confirm Email Role*Select your roleFacultyStaffResidentPostdoctoral FellowGraduate StudentUndergraduate StudentOtherName/ID of ATLAS query*De-identified line-level data elements can only be provided based on previously created ATLAS query PI Full Name*Name as reflected on Project, IRB or Protocol. For deidentified dataset, please use your information in PI fields. First Last PI Email Address*PI Email Address as listed on IRB Enter Email Confirm Email PI College/Department*Please list your College and Department Point of Contact Full NamePoint of Contact for additional information First Last Point of Contact Phone NumberPoint of Contact for additional informationPoint of Contact Email AddressMust be ufl.edu, jax.ufl.edu or shands.ufl.edu email address for secure transfer Enter Email Confirm Email IRB Number*The IRB number has one of following formats: IRB123456789, CED12345678, WIRB12345678, wcgIRB12345678. Approval number*Provide the number generated by the nonhuman tool HiddenIRB Number*We ONLY provide MRNs and no other data elements for this type of data request IRB Title* IRB Protocol*Please upload a copy of your APPROVED IRB documents. For the list of necessary document, please see https://idr.ufhealth.org/wordpress/files/2022/03/DocumentsForDataRequests.pdf . Failure to provide all required documents will delay processing of your request. Drop files here or Select files Accepted file types: pdf, xlsx, docx, Max. file size: 125 MB. Documents*Please upload the approval and the confidentiality agreement. Drop files here or Select files Accepted file types: pdf, xlsx, docx, Max. file size: 125 MB. Project Title* IRB Expiration Date MM slash DD slash YYYY QIPR number* QIPR Title*Please write the full title of your project Project Description*Describe the intent of the project. Use IRB Title/Description when pertinent. **PLEASE DO NOT INCLUDE ANY PHI**Inclusion Criterion*List all your inclusion criterion. Please include ICD and/or CPT codes. **PLEASE DO NOT INCLUDE ANY PHI**Select dataset domain*NOTE: All data will be fully de-identified and dates shifted. OMOP Covid19 dataset OMOP Cancer patients dataset Select the type of de-identified data elements you wish to receive*NOTE: All data will be fully de-identified and dates shifted. All OMOP data (see link above for list of all available OMOP data) OMOP data and additional non-OMOP data elements Data Elements*List all OMOP and non-OMOP data elements you are requesting from the IDR for your study or protocol. **PLEASE DO NOT INCLUDE ANY PHI ON THIS FORM**Data Elements*List all data elements you are requesting from the IDR for your study or protocol. Do NOT include data elements that you will collect yourself by doing chart review or from other sources. Ensure the requested data elements are listed in your approved IRB. **PLEASE DO NOT INCLUDE ANY PHI**What questions do you have for the IDR Research Team?*Please provide specific questions to better connect you with the best resources within the IDR.For Jacksonville investigators, are you working with the Center for Data Solutions (CDS) on this project?*NoYesConfidentiality Agreement - ATLAS access*UF Health Open Access De-identified Databank: In order to use this coded de-identified database as the sole source for your research without first obtaining IRB approval, you must agree that you will not attempt to re-identify individuals in anyway at any time. Research publications based on these data should publish only aggregate analyses. Research publications using these data should acknowledge the UF Clinical and Translational Science Award and the UF Health Integrated Data Repository team. Read and understand Confidentiality Agreement Confidentiality Agreement: OMOP de-identified line-level data*UF Health Open Access De-identified Databank: In order to use this coded de-identified database as the sole source for your research without first obtaining IRB approval, you must agree that you will not attempt to re-identify individuals in any way at any time. Data should be stored at password-protected encrypted servers at all times. If you wish to share data outside of the UF/UF Health organization, please contact Office of Sponsored Research to obtain Data Use Agreement. Research publications based on these data should publish only aggregate analyses. Research publications based on these data should publish only aggregate analyses. Research publications using these data should acknowledge the UF Clinical and Translational Science Award and the UF Health Integrated Data Repository team. Read and understand Confidentiality Agreement Confidentiality Agreement: Domain-specific OMOP datasets*UF Health Domain-specific OMOP de-identified datasets for Research: These data are approved for use by the UF and UF Health community only, and approved only for research purposes. These data should not be shared outside of the UF/UF Health organization. These data should not be used for non-research purposes. Research publications based on these data should publish only aggregate analyses. Users of these data agree not to attempt to re-identify any patients whose data are included in the data. Research publications using these data should acknowledge the UF Clinical and Translational Science Award and the UF Health Integrated Data Repository team. UF Health care teams interested in these data for operational or clinical purposes should contact the IDR team IRBDataRequest@ahc.ufl.edu for additional guidance. Read and understand Confidentiality Agreement EmailThis field is for validation purposes and should be left unchanged.
