Office of Research

Data Request Questionnaire Retrospective Chart Review

Before you begin:

For studies with funding, please note that an Initial Budget Request for IT services must have been submitted before study approval. If you are submitting a returning or follow‑up request, please ensure that your budget has been updated to include any additional IT services needed, as a new or revised budget request may be required.

The person submitting this form must be listed as a member of the study team, and all information provided must match the JHS‑approved protocol. Any differences or deviations from the protocol may delay processing.

Once IT completes your request and delivers the data, you will have 30 days to review and request any corrections. After 30 days, any additional changes will require submitting a new request.

Please correct the following fields before submitting:

    Accessibility Note: As you fill out this form, new fields may appear based on your answers. These will always appear below — you will never need to revisit a field you’ve already completed.

    * Represents a required field


















    Date Range of Medical Records Requested



     

    Gender (select all that apply):

    Age Range





     

    Race (select all that apply):

    Ethnicity (select all that apply):

    Patient Type (select all that apply):








    Facility (select all that apply):




    Jackson Health System respects your privacy and contact information will NOT be shared or sold to any third parties under any circumstances.

    By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our Privacy Policy. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.