Study Data Extraction Request Form
Use this form to request a data set, prospective recruitment list, or retrospective cohort identification. If you are requesting simple counts or a quote for CDW-R services to include within a grant proposal or IRB application, please use our Quotes & Counts form.
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.
If IRB-approved study: Inclusion/exclusion criteria must match the IRB protocol or be a subset of IRB protocol criteria. We cannot pull data from medical records that are not in-line with what is described in your IRB protocol.
- Include all relevant ICD-10 and/or CPT codes.
- Fully spell out all medications, treatments, surgeries, and/or procedures (do not use acronyms).
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.
If IRB-approved study: The CDW-R can only pull data within the date range reflected in the HIPAA section of the study's INSPIR application.
Data Fields: List all data fields you want the CDW-R to provide to you in the data set.
If IRB-approved study: The CDW-R can only pull data fields listed in the HIPAA section of the study's INSPIR application.
- Include all applicable ICD-10 and CPT codes.
- Fully spell out all medications, treatments, surgeries, and/or procedures. Do not use acronyms.
- List only the data fields you need the CDW-R analyst to pull for you. Do not include any data that you will hand abstract or collect via primary collection. If you are unsure about what information to include in your request, please email firstname.lastname@example.org to set up a quick consultation.
- Requested data fields may also be uploaded as a Word document or Excel file below.
Attachments: Upload the list of data fields and/or other relevant study documents.
- Reference P.I. Name and Study H-# in file title.
- 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.
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.
If an account number is not including in this data request form, it is the research team's responsibility to email email@example.com with the account information when available.
Data requests will not be added to the CDW-R queue until account information is supplied.