Get Data Extraction Report Request Form

This guide provides clear and detailed instructions for completing the Data Extraction Report Request Form online. Following these steps will ensure that you efficiently and accurately submit your request for a report from Clinical Information Systems or UTSHS Information Systems.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the Data Extraction Report Request Form and open it in your online editor.
2. Begin by filling out the requestor's information. This includes your name, title, department, telephone number, and mail code. Ensure that all details are accurate and reflect your current position.
3. Next, complete the approver's information section. Enter the name, title, department, telephone number, and mail code of the person approving your request.
4. Indicate your purpose for requesting the report by placing an X in one of the options within either Column A or Column B. Remember, you cannot select options from both columns.
5. Select whether you require a fully de-identified report, a limited data set, or protected health information. Use the attached definitions if you need clarification.
6. Provide a valid IRB number, which is necessary for processing your request.
7. In the detailed description section, outline the information required in the report. Specify the data elements needed, how you want the data sorted, and the time period it should cover.
8. If your request involves information from another department, describe your operational need for that information.
9. Indicate the date you need the report by, ensuring it allows adequate time for processing.
10. Certify your request by typing your name and the date, affirming that the request aligns with the minimum necessary information requirement and intended purpose.
11. Have the approver type their name and date as confirmation of the approval for the request.
12. Once all sections are completed, review the form for accuracy, save your changes, and then you can download, print, or share the fully completed Data Extraction Report Request Form.

Complete your Data Extraction Report Request Form online today for timely access to essential information.