CRIS Online Service Request Form

To request a CRIS service, please complete the following form: Principal Investigator Last Name: First Name: Email: Telephone: Massey Research Program Affiliation: If requester other than the PI, please complete Last Name: First Name: Email: Telephone: Title of Project: Brief Description of Project (to direct data needs)

Category of Research Work (Check all that apply) □ Manuscript Support □ Pre-study 9valuations (sample size, number of patients meeting certain criteria, provision of potentially eligible list of patients for a study etc.) □ Grant Submission □ Abstract or Poster Presentation □ Support for Funded Grant Proposal □ Other

Are you requesting Patient Identified Data? □ Yes □ No If ȅesΣ Please provide your IRB approval number HM Also please attach a copy of the IRB approval letter for this project. To assist us in prioritizing your request - how soon do you need the data? weeks Please describe any factors that might influence your timeline:

1.□ Cohort Discovery (capture and linkage of data/patients with selected diseases, conditions or treatments to identify cohorts of patients with those characteristics.)

2.□

Custom Report or Query Generation

a.□ Identifying number of patients (sample size/power calculations) b.□ Preliminary data assessment for other purposes (ieΣ feasibility for clinical trials, to support

a table in a manuscriptΣ etcΦ) 3.□

Pre-study patient identification in support of clinical trials

a.□ Involves CTED tracking or AutoMatch query b.□ Need access to CTED tracking (requires IRB approval) c.□ Development of ongoing Automated Matching queries d.□ Involves other custom query development (ieΣ Data AnalyticsΣ etcΦ) 4.□

Clinical Annotation of Tissue Specimens

a.□ Custom linkages for routine patient and clinical characteristics for selected sets of patients with tissue

b.□ Includes above with patient identifiers (requires IRB) c.□ Without patient identifiers through Honest Broker (coming soon) 5.□

Developing Custom Database Tools (includes custom reports, queries, add on to existing systems, custom reports from CTED Tracking, AutomatchΣ etcΦ)

6.□

Development of Custom Datasets

a.□ Clinical and nonclinical datasets integrating data from internal and external sources for a particular study (with patient identifiers requires IRB)

b.□ Request meeting with CRIS staff to identify data needs (ieΣ which data will best support your research)

c.□ Data required are known to the investigator providing list to CRIS staff 7.□

Supporting investigatorπdeveloped queries using existing tools (includes working with investigators to develop custom queries for their research, training investigators or staff in use of CTED Tracking, AutoMatchΣ etc.)

8.□

Support for CRIS Tools (if checkedΣ specify tool needed below)