TN-POPnet Data Use Request Form

Name of Investigator

Investigator's Title

Phone number

Phone

Name of Proposed Study

Type of Study

Are you requesting access to TennCare data?

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

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

What is the IRB approval status of your proposed study?

List the names of all co-investigators

What is your proposed project start date?

What is your proposed project end date?

mm/dd/yyyy

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

mm/dd/yyyy

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:

Copy and paste your research proposal below.

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

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

7. References (APA Style)

Send me a copy of my responses