TN-POPnet Data Use Request Form

TN-POPnet Data Use Request Form

Name of Investigator*

Investigator's Title

Phone number*

Phone

Email*

Name of Proposed Study*

Type of Study*

Select

If other type of study, specify

Please justify why you need access to identifiable data*

Are you requesting access to TennCare data?*

(TennCare data use requires additional approvals, processing time, and investigator responsibilities)

Select

Will data only be accessed and analyzed on UTHSC servers (i.e., without download or transfer to other computers or servers)?*

Select

Data cannot be downloaded or transferred to other computers or servers without the explicit approval of the IRB and Data Governance Board. Data also has to be de-identified.

What is the IRB approval status of your proposed study?*

Select

You are required to include the TN-POPnet Administrators as a study contact on your IRB (Annie Ninan aninanl@uthsc.edu & Sultan Mahmood mmahmu10@uthsc.edu)

IRB Number*

IRB Approval Date

Is the TN-POPnet Data Engineer included on the IRB application?*

Select or enter value

You are required to include the TN-POPnet Administrators as a study contact on your IRB (Annie Ninan aninanl@uthsc.edu & Sultan Mahmood mmahmu10@uthsc.edu)

List the names of all co-investigators*

What is your proposed project start date?*

What is your proposed project end date?*

What is your deadline for getting access to TN-POPnet data for your project?*

What is your funding source?*

Describe the PHI protection plan for your proposed study*

Research Proposal Section

Copy and paste your research proposal below.*

Please use the following subheadings if applicable:

Purpose
Specific Aim 1:
Hypothesis
Specific Aim 2:
Hypothesis
Rationale
Research Design
Study/Project Population:
Population
Inclusion Criteria
Exclusion Criteria
Study/Project Procedures
Analytic Plan

Copy and paste your research proposal below.*

5b.Outcome Measures (Please consult the TN-POPnet Data Dictionary for available variables)

Primary: (List Variables)
Secondary: (List Variables)
Covariates: (List Variables)

6. Are there any special ethical considerations that apply to your proposed project?*

7. References (APA Style)

Upload IRB Approval and the Study Protocol*

Drag and drop files here or

Send me a copy of my responses

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