Study Data Extraction Request FormUse this form to request a
data set, prospective recruitment list, or
retrospective cohort identification.
If you need prep-to-research aggregate counts or a quote to include in a grant proposal, please use our Quotes & Aggregate Counts form instead.
CDW-R Data Request Information
Medical Record Selection: How will the CDW-R identify the medical records to pull data from?
Define the inclusion criteria and exclusion criteria for the medical records from which to build the requested data set.
- Include all relevant ICD-10 and/or CPT codes.
- Fully spell out all medications, treatments, surgeries, and/or procedures (do not use acronyms).
- Provide all form and order names as they appear in Epic.
Inclusion/exclusion criteria must match the IRB protocol or be a subset of IRB protocol criteria. CDW-R may only pull data from medical records as described in your IRB protocol.
If your study team will supply a list of enrolled patients/MRNs to CDW-R: DO NOT include any patient identifiers in this form. Noting below that "the study team will provide patient list" is sufficient for this form. The CDW-R team will be in contact after request submission to coordinate secure transfer of the patient/MRN list.
Record Date Range: Enter the date range for the requested data.
The range may be exact dates (March 1, 2018 - December 31, 2018) or may be a specified period of time pre/post study enrollment.
CDW-R can only pull data within the date range reflected in your study's INSPIR application.
Cohort size
- If providing inclusion/exclusion criteria: What is the estimated cohort size that you expect CDW-R to identify using the provided inclusion and exclusion criteria?
- If your study team will supply a list of enrolled patients/MRNs to CDW-R: How many unique patients will be provided to CDW-R?
Data Fields: What data do you need from CDW-R?
List all the data fields you want the CDW-R to extract and provide to you in the data set.- Include all relevant ICD-10 and/or CPT codes.
- Fully spell out all medications, treatments, surgeries, and/or procedures (do not use acronyms).
- Provide all form and order names as they appear in Epic.
- List only the data fields you need the CDW-R analyst to extract for you. Do not include any data that you will hand abstract via supplemental chart review nor data collected via primary collection methods.
- Requested data fields may also be uploaded as a Word document or Excel file below.
If IRB-approved study: The CDW-R can only pull data that are listed within your study's INSPIR application. Please ensure all data you are requesting is reflected in your IRB.
Attachments: Upload the list of data fields and/or other relevant study documents.
- Reference P.I. Name and Study H-# in file title.
- DO NOT include any patient identifiers in this form.
- Excel and Word docs are preferable. Please avoid uploading PDF documents.
- Select "Upload another file" to upload additional files.
The CDW-R requires mentors to be engaged in the trainee's data request process. Mentors should plan to attend the initial data request consultation with the trainee.
Funding Information
The CDW-R charges an hourly fee for all projects beyond simple count requests. Research teams are encouraged to review the Fees & Billing policies before submitting a data request.
