IRB Approved Research Data Request

IRB Approved Research Data Request

MIEMSS is prohibited by law from releasing identifiable patient data. In rare instances, MIEMSS may determine to participate in IRB approved research, using identifiable data, when MIEMSS determines that the research would benefit the citizens of Maryland. The MIEMSS Data Access Committee (DAC) reviews detailed research requests for MIEMSS's participation in human subjects research to determine compliance with legal requirements and to recommend a limited number of research projects for MIEMSS participation.

This form is to be used to request DAC review of proposed research projects. Submission of a request using this form does not guarantee that data will be released.

Project Name*

Today's date*

Requester Information

First Name*

Last Name*

Requestor's Affiliation*

Street Address

City

State*

Zip Code*

Email Address*

Contact Phone*

Research Project Information

Project Decription*

Provide a general description project for which the data will be used. Supplement as necessary with documents in the File Upload section below.

Data Requested*

Describe the data that you are seeking, including the source of the data and a list of the specific data elements requested. You may supplement with documents uploaded below.

Trauma Data Dictionary Adult

Trauma Data Dictionary Pediatric

eMEDS: Data Dictionary

Specify the date range of data requested*

From:

Specify the date range of data requested*

To:

Will the data be used for the purpose of publication?*

Yes

IRB Approval*

Please confirm that you have applied for or obtained approval from an Institutional Review Board for any request that requires the disclosure of identifiable data. You must upload your IRB submission and approval below for your request to be considered.

MIEMSS Participation in Research*

I acknowledge that MIEMSS may require collaboration with MIEMSS on projects using data supplied by MIEMSS, and that MIEMSS shall be entitled to pre-publication review of any publications related to the data requested.

DUA Acknowledgement*

I acknowledge that I or my sponsoring institution will be required to sign a Data Use Agreement, in a form determined by MIEMSS, before I can receive any data that may be deemed confidential.

File upload

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