Please direct any questions via email to healthR3@pitt.edu.
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).
If the study consents patients AND does NOT require R3 service to obtain patient data (i.e. first two boxes are checked in the form above), then the R3 workflow is complete without submitting the intake form, and submission of this form is not enabled.If the activity uses EHR data and does NOT need R3 assistance then the approved IRB Protocol Identifier is required to complete R3 attestation.By submitting this form, the following is asserted by the PI:Principal Investigator Attestation for Use of UPMC EMR Data for Research Purposes:I attest, by submitting this intake form, as Principal Investigator of this research project, that the data from the electronic medical record will be accessed, used, and stored in a manner that: - is consistent with the information provided to R3 - is in compliance with the IRB approved research project including any applicable DUA - is in accordance with all UPMC and University of Pittsburgh policies related to the access, acquisition, and storage of electronic protected health information for research purposes - abides by all local, state, and federal guidelines related to the security of electronic protected health information, including all HIPAA regulations.I understand that data must be stored in a secured environment at all times.This includes ensuring that the computer and any media (such as CD-ROMs, thumb drives, removable drives) is encrypted and password protected.Further, I understand that data should not be sent through e-mail.If I have reason to believe that the confidentiality of the data or passwords used have been compromised, I will contact R3 (HealthR3@pitt.edu) immediately.In using the R3 service, I am designated as a CTSI investigator using UPMC data, and as such, I am required to notify R3 of all uses of this UPMC data (posters, presentations, abstracts, papers, etc.) in advance of publication.I will email these to HealthR3@pitt.edu with my R3 request number in the subject line.
After R3 Intake is successfully submitted, the next step in the R3 workflow is to discuss feasibility of the request.After submission, please email healthR3@pitt.edu with proposed times that work for your PI and team.Please remember to acknowledge the Clinical and Translational Science Institute (CTSI) in all publications that received services through R3.The CTSI provides the following citation for your convenience: The project described was supported by the National Institutes of Health through Grant Number UL1 TR001857.