CFAR Clinical Research Data Request (CCRD) Form
(TMH-Immunology Center)

Save & Return

Save your progress and complete this form later. (optional)

Requesting Faculty Member: (Must be an individual with an academic appointment at Brown University who agrees to assume FULL responsibility for the identified project)
Are you affiliated with The Miriam Hospital Immunology Center (MIC) *
The Miriam Hospital Immunology Center Collaborator:
(If the requesting faculty member is not affiliated with The Miriam Hospital Immunology Center (MIC) a collaborator from the MIC must be identified and who will assume responsbility of the data confidentiality)
If you are not the faculty member named on this form, please complete the following: (i.e. fellow, data manager, nurse, medical student)


IRB Approval 
Please note: To receive identified data from the CCRD for research purposes, approval is required from the IRB via one of the following mechanisms *

Data Utilization:
(Please Note:  If using this data for a publication, please remember to acknowledge the Providence/Boston CFAR-NIH Grant #P30AI042853)

Preparing a grant application

Will this data be used for: (Patient level data will not be provided for these options) *

Clinical Purposes

Is this a recurring request: (Recurring requests will be provided, however, requests should be submitted for data sets as often as necessary (monthly, quarterly, etc.) Once the initial approval is granted additional reviewer approval will not be required unless there is a change in the data items requested *
I acknowledge that this data will only be released to the faculty member noted on this form and further certify that it will only be released or made available to individuals with appropriate human subject training ( *
Signature *