Office of Research

What is the IRB #? (Type the 8digit IRB ePROST#. If the identifier starts with “SITE” then include the word “SITE”) *

Is there an estimated budget needed for this study? Y/N *

Is this project JHS Approved? *

Principal Investigator’s/ Requestors Name: *

Principal Investigator’s/ Requestors Department: *

If applicable, who is the Study Coordinator? *

Title or Brief Summary of Request: *

Is this Pre-Submission Feasibility request for a prospective /retrospective project?*

Is this a funded project, if no please provide a short explanation?*

What is the funding source?*

Inclusion/Exclusion Criteria (Please provide the inclusion/exclusion criteria):*

How many records approved for this study (This is located in the IRB approved Protocol)?*

Date Range of Medical Records Requested for Review:*

Gender(M/F): *

Age Range (1-150):*

Race: *

Ethnicity:*

Patient Type (Emergency Department, Inpatient, discharged, Outpatient, Deceased):*

ICD-9 Codes (If none put N/A):*

ICD-10 Codes (IF DATE RANGE FOR DATA INCLUDES >2015 please include ICD-9 Code)?*

Procedure Codes (CPT) (If none put N/A): *

Procedure Codes (DRG) (If none put N/A): *

Laboratory Tests (If none put N/A): *

Medications (If none put N/A): *

Implants or Devices (If none put N/A): *

Facility? (Jackson Health System (All Facilities), Jackson Memorial, Holtz Women’s & Children’s, Jackson Behavioral Health, Jackson North, Jackson South, Jackson West, Ambulatory Care Clinics, Urgent Care Clinics, Other:):*

Any Additional Instructions:*

Expected Timeline for data request to be completed (When do you expect or require the data pull to be completed):*