SELECT TOP 1 ID FROM DataRequestForm ORDER BY ID DESC

NEONATAL DATA REQUEST FORM

REQUESTER INFORMATION:

First Name

Last Name

Email

Phone Number

Date of request: #DateFormat(Now(), "mm/dd/yyyy")#

Request on behalf of:

Self

Other:

DATA DETAILS

Data Source

What specific data are you requesting?

Will the requested data include any Protected Health Information?

Yes

No

Show PHI Data Elements?

Yes

No

Is request for:

Raw Data

Report

Statistical Analysis

Data needed by:

PURPOSE OF DATA REQUEST

What is the purpose of your request?

Organizational

Research

Is there a grant or study associated with your data request?

Is funding available for your data analysis?

Yes

No

Describe the organizational or clinical purpose for this data request:

What questions are you trying to answer, what do you want to learn from the data?

How will you use the information you're requesting?

DATA FORMAT

Will the data need to be sorted?

Yes

No

Select file format for the data:

Adobe Acrobat (PDF)

Excel (XLS)

Graphs and Charts

Other:

Other questions or comments:

DISCLAIMERS

I understand that all TCH IDS information is and remains the property of TCH IDS. I agree to use the requested information only in the fashion described above and will dispose of all CONFIDENTIAL and PROPRIETARY information in compliance with TCH IDS Policy and Procedure. I further agree to maintain the data only on TCH IDS facilities and/or on TCH IDS information assets.

I have read and agree to the statement above

Authorship: Irrespective of payment, co-authorship is expected on manuscripts and conference presentations/posters to which the statistician makes a substantial intellectual contribution in terms of study design, data acquisition, data analysis, interpretation or writing. Many journals require that "Any part of an article essential to its main conclusions must be the responsibility of one author ..."
(Academic Medicine Complete 2006 Instructions for Authors, http://www.academicmedicine.org/)

I have read and agree to the statement above

No data shall be stores on USB

I have read and agree to the statement above

No data shall be transmitted through non-TCH email. (Do not use personal email)

I have read and agree to the statement above

All data shall be returned or deleted at termination of employment.

I have read and agree to the statement above

INSERT INTO DataRequestForm (ID, FirstName, LastName, Email, Phone, RequestDate, Requester, DataSource, DataDescribed, PHI, PHIdata, RequestType, DateRequired, PurposeType, Paperwork, Funding, PurposeDesc, Answers, InfoUse, Sorted, FileFormat, FileOther, Comment, Disclaimer1, Disclaimer2, Disclaimer3, Disclaimer4, Disclaimer5) VALUES (#Record#, '#FORM.First#', '#FORM.Last#', '#FORM.Email#', '#FORM.Phone#', '#DateFormat(Now(), "mm/dd/yyyy")#', '#Requester#', '#FORM.DataSource#', '#FORM.DataDescribed#', '#FORM.Health#', '#FORM.PHI#', '#FORM.RequestFor#', '#DateRequired#', '#FORM.RequPurpose#', '#FORM.Paperwork#', '#FORM.Funding#', '#FORM.OrgPurpose#', '#FORM.Answers#', '#FORM.InfoUse#', '#FORM.Sorted#', '#FORM.FileFormat#', '#FORM.FileOther#', '#FORM.Comment#', '#FORM.Disclaimer1#', '#FORM.Disclaimer2#', '#FORM.Disclaimer3#', '#FORM.Disclaimer4#', '#FORM.Disclaimer5#')

Attention:

Data Request Form was submitted with the following information:

REQUESTER INFORMATION:
Name: #FORM.First# #FORM.Last#
Email: #FORM.Email#
Phone: #FORM.Phone#
Date: #DateFormat(Now(), "mm/dd/yyyy")#
Requested by: #Requester#

DATA DETAILS:
Data Source: CHND Other Unknown VON
What specific data are you requesting:
#FORM.DataDescribed#

Will the requested data include any Protected Health Information? YesNo
Show PHI Data Elements? YesNo
Is Request for? Report Statistical Analysis Raw Data
Data needed by: #DateRequired#

PURPOSE OF DATA REQUEST
What is the purpose of your request? Research Organizational
Is there a grant or study associated with your data request?
#FORM.Paperwork#
Is funding available for your data analysis? YesNo
Describe the organizational or clinical purpose for this data request:
#FORM.OrgPurpose#
What questions are you trying to answer, what do you want to learn from the data?
#FORM.Answers#
How will you use the information you're requesting?
#FORM.InfoUse#

DATA FORMAT
Will the data need to be sorted? YesNo
Select file format for the data: Excel Graphs and Charts Adobe Acrobat (PDF) Other: #FORM.FileOther#
Other questions or comments:
#FORM.Comment#

DISCLAIMERS
Disclaimer ##1: YesNo
Disclaimer ##2: YesNo
Disclaimer ##3: YesNo
Disclaimer ##4: YesNo
Disclaimer ##5: YesNo