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)

Last Name: *

First Name: *

Academic Title: *

Email Address: *

Are you affiliated with The Miriam Hospital Immunology Center (MIC) *

Yes

No

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)

Last Name (MIC):

First Name (MIC):

Academic Title (MIC):

Email Address (MIC):

If you are not the faculty member named on this form, please complete the following: (i.e. fellow, data manager, nurse, medical student)

Last Name (other):

First Name (other):

Academic Title (other):

Email Address (other):

Type of data request: *

Data Items Requested:
(Please include a detailed list of variables, i.e. last name, first name, etc. Only the data items listed can be provided. If additional data items are required you must submit a
new request form.) *

Data Items Requested:
Only summaries (no patient level data) will be provided. For example, total number of participants with a specific attribute. *

Please explain the purpose for requesting this data *

Date the data is needed: (Please allow at least 3 weeks to process the data request)
Please note: We will review this request and estimate how much time it will take to complete * +

Research

Grant/Study Title: *

Primary Investigator *

Co-Investigators(s)

Type of funding *

Funding Agency: *

Grant Number (if applicable)

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 *

IRB Approval Granted

Researcher Request for Reviews Preparatory to Research has been approved

Waiver of Authorization obtained

IRB Approval Date * +

Upload IRB approval documentation *

Upload Preparatory to Research approval *

Upload Waiver of Authorization *

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

Study participant recruitment

Chart review

Publications

Other Other

If other, please explain data utilization

Preparing a grant application

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

Preparing a grant application

Exploring study feasibility

Name of proposed principal investigator *

Awarding Institution: *

Proposed Title:

Proposed submission date: +

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 *

Yes

No

How often will this data be needed: *

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 (http://www.lifespan.org/research-and-clinical-trials/office-of-research-administration/research-administration-training/) *

I agree

Signature *

clear