Get Uahs Research Intake Application Retrospective Chart Review/crdw Request Form 2020-2025

Completing the UAHS Research Intake Application Retrospective Chart Review/CRDW Request Form is essential for initiating a research study that requires a review of medical records, data, or specimens. This guide provides clear and supportive instructions to help you navigate each section of the form effectively.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the date at the top of the form to indicate when you are submitting your application.
3. Provide the study contact information: enter the last name, first name, and phone number of the primary contact person for this study.
4. Enter the UA email address of the study contact to ensure communication is directed appropriately.
5. In the Study Overview section, provide the study protocol number or nickname for easy reference.
6. Specify the principal investigator's name and their UA email address.
7. Select the college associated with the study from the provided options.
8. Choose the clinical department, if applicable, by selecting from the dropdown menu.
9. If additional email addresses for study-related correspondence are needed, list them here, separating each with commas.
10. Enter the protocol title relevant to your study.
11. In the Medical Center Information section, indicate whether the study will review medical records, data, or specimens by selecting 'Yes' or 'No'.
12. Select the medical center from the options provided (Banner or Dignity).
13. Determine if any non-affiliated study staff will have access to Protected Health Information (PHI) and select the appropriate response.
14. If Cerner data is required, answer 'Yes' and ensure you upload the necessary CRDW Request Form as instructed.
15. Address any potential need for study agreements or contracts: select the appropriate responses regarding sponsor agreements.
16. Fill in the study sponsor or organization name associated with your study.
17. Provide contact details for the contract negotiator, including name, email address, and phone number.
18. Similarly, provide the budget negotiator's contact information.
19. Include any comments, special instructions, or notes in the designated section.
20. Ensure you attach all required documents as listed, such as the Application for Human Research and list of research personnel, before submission.
21. Once all fields are completed, save changes, and choose to download, print, or share the form as needed.

Complete your documentation online to ensure a smooth submission process.