Health Record Research Request (R3) Intake

Please direct any questions via email to
Required items marked with *

Principal Investigator's Name: *
Principal Investigator's Email Addr.: *
Principal Investigator's Department: *

Additional Contact Name:
Additional Contact Email:

Project Description (limit 2000 characters): *
State hypothesis, objectives, or aims related to use of health records.
Do NOT include any protected data (e.g. NO patient identifiers).

IRB Protocol Identifier (if available):
IRB Protocol Title (if available):

Check each of the following that apply to your study.
Individual signed informed consent will be obtained for each patient (subject).
I will be obtaining ALL data on my own, WITHOUT the help of R3.
I am interested in receiving an estimate of R3 service costs (e.g. for a grant proposal).
I am interested in receiving counts of patients to plan my research (e.g. prep to research).
I am interested in receiving a list of patient identifiers (e.g. for recruitment OR chart review).
I am interested in receiving patient data from R3 (e.g. identified or de-identified).

After R3 Intake is successfully submitted, the next step in the R3 workflow is to discuss feasibility of the request.
After submission, please email with proposed times
or visit us without appointment during R3 office hours (see for dates and times).
If the study consents patients AND does NOT require R3 service to obtain patient data (i.e. both boxes are checked in the form above),
then the R3 workflow is complete upon submission and further communication is not required.