ACTRI BMI - DECS Service Request Form

ACTRI Biomedical Informatics (BMI) - DECS Service Request Form
Data Extraction Concierge Service (DECS)
If you have questions about this form, or general DECS related questions please attend our weekly virtual office hours. Simply join the zoom meeting link on Thursdays from 1:00PM – 2:00PM

https://uchealth.zoom.us/j/81732217241?pwd=Yk9rc0NPTGRTMnFxQkxhSTFaVEo2UT09&from=addon
Which UC sites are you requesting limited/identified data from?
UC Sites
Data Description
Name of data set
Brief description of data/statement of work
Requested Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Inclusion Criteria (Specify the conditions to include patients in the cohort) (max 5000 chars)*(The diagnosis/condition should be in ICD9/10 codes)

0/5000
Exclusion Criteria (Specify the conditions to exclude patients from the cohort) (max of 5000 chars) (The diagnosis/condition should be in ICD9/10 codes)

0/5000
Formulas (Define any formulas required for data field generation)
List of Variables to be included in the Data Set separated by commas (e.g. Gender, Age, etc)
Does your project require extraction of clinical notes?
DECS Comments
Additional Documents:

Browse Files
Combine multiple files into one .zip or .pdf file if necessary! Cancelof
- Study Information
- Study Title
- IRB Number
  6-digit numerical value.
- ACQUIRE Number
  3-4 digit numerical value.
- Do you have a HIPAA Waiver?
- Please attach HIPAA waiver documentation.
  
  Browse Files
  Combine multiple files into one .zip file if necessary! Cancelof
- PI Information
- PI First Name
- PI Last Name
- PI Full Name
- PI Email
  Please use @health.ucsd.edu email address if you have one!
- PI Department
- Please indicate PI's ACTRI membership level
- If you are not an ACTRI member yet, please click here to review membership eligibility criteria and submit your application. Once submitted, please select the applicable membership level from the above options to proceed.
- Contact Person Information
- Contact Person same as PI?
- Contact Name
  
  FirstLast
- Contact Email
  Please use @health.ucsd.edu email address if you have one!
- Contact Department
- Recharge Information
  
  Please provide valid fund manager and OFC chartstring information for recharge purposes.
  
  Click here to review current ACTRI recharge rates.
- Fund Manager Name
  
  First NameLast Name
- Fund Manager Email
  Please use @health.ucsd.edu email address if you have one!
- OFC Project:
  Always required! (7 digit numerical value)
- OFC Task:
  Always required! (1-3 digit numerical value)
- Funding Source
  Required for sponsored projects only! (5-7 character alphanumerical value)
- Providing incorrect or incomplete OFC chartstring information will require further clarification and delay the process! Contact your fund manager or use the chartstring verification tool (requires VPN connection) to ensure chartstring accuracy prior to submission.
- Additional Information
- Funding Agency
  
  Other
- Industry-sponsored studies are not eligible to receive voucher support. To proceed with your service request, please scroll up to the ACTRI Voucher Program section and unselect 'Yes'.
- Organizational Affiliation
  
  Other
- Any further information or comments you would like to submit with this request:
- BMI Service
- VRD FP Email
- Stop submission active?
- Request Date
  
  YearMonthDay
  4 digit year, 2 digit month, 2 digit dayDateHourMinutesAM/PM Option
- Should be Empty:

ACTRI Biomedical Informatics (BMI) - DECS Service Request Form

Recharge Information