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?

UCSDUCLAUCSFUCIrvineUCDavisUC Health Data Warehouse
UC Sites
Data Description
Name of data set*
Brief description of data/statement of work*
Requested Due Date*

MonthDayYear
Date
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?*

YesNo
DECS Comments
Additional Documents:

Browse Files
Combine multiple files into one .zip or .pdf file if necessary! Cancelof

--- Study Information Section
Study Information
Study Title*
IRB Number*
6-digit numerical value.
ACQUIRE Number
3-4 digit numerical value.
Do you have a HIPAA Waiver?*

Yes, issued by UCSDYes, issued outside of UCSDNot yetNot applicable
Please attach HIPAA waiver documentation.*

Browse Files
Combine multiple files into one .zip file if necessary! Cancelof

--- PI Section
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*

General (existing or pending)Associate (existing or pending)Affiliate (existing or pending)No membership / Don't know
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.

ACTRI Biomedical Informatics (BMI) - DECS Service Request Form