CARe Submission Form

All research projects that access the UPMC electronic medical record (EMR) must be submitted to the Center for Assistance in Research using eRecord (CARe) per UPMC policy with the exception of clinical trials that are routed through the UPMC Office of Sponsored Programs and Research Support (OSPARS).

 Please complete all fields below and a CARe representative will contact you. Send all general inquiries and questions about completing this form to CARe@upmc.edu, or call 412-864-3491 for assistance.

Project Information

Project Title:  * 
Deadline:   ex. 01/01/2013  *    
Brief Project Description:  *  
IRB Submission Status:  *  
IRB#:

Principal Investigator's Information

PI Honorific:  *  
PI First Name:  *  
PI Last Name:  *  
PI Degree:  *  
PI Title:  *  
PI Affiliation:  *  
   If PI possesses both UPMC and University affiliations, please select University of Pittsburgh.
PI Address:
PI Phone:   ex. 111-222-3333  *    
PI Email:  *    

Requestor's Information

Requestor Honorific:
Requestor First Name:
Requestor Last Name:
Requestor Title:
Requestor Address:
Requestor Phone:   ex. 111-222-3333  
Requestor Email:  

EMR Access

Select all individuals and/or groups that will be accessing and/or extracting from the UPMC electronic medical record (EMR) for this research project. Select all that apply.


CARe can facilitate your data request by working with the eRecord teams to obtain UPMC EMR data or to program an alert or flag in the UPMC EMR. If you would like CARe assistance, please check this box and select the Request Type that best suits your needs. Complete the rest of the form and a CARe representative will contact you. If assistance from CARe is needed for more than one Request Type, please complete a separate submission form for each type.


If you are using the services of a certified Honest Broker for this research project, please check this box and provide the name and number of the certified Honest Broker below. If you would like CARe to act as your certified Honest Broker, please note that in this section.


If the PI is accessing and/or extracting data from the UPMC EMR for this research project, please check this box and answer the questions below.


If someone other than the PI is accessing the UPMC EMR for this research project, please check this box and answer the questions below. List all persons accessing the UPMC EMR for this research project.

Scope

Provide the following information about the research project.

List all data fields to be accessed and/or extracted from the UPMC EMR for this research project (i.e., as described in section 2.14 of OSIRIS: Describe the medical record information that will be collected from the UPMC/Pitt HIPAA covered entity):

Approximate number of individual patient medical records accessed for this study (i.e., estimated cohort size):
Date range of records to be extracted: Start date of records:
<September 2014>
SunMonTueWedThuFriSat
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011

No specified record start date
End date of records:
<September 2014>
SunMonTueWedThuFriSat
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011

No specified record end date
Patient visit type:
Gender:
Will any racial or ethnic subgroups be explicitly excluded from the participation?
If yes, please specify the subgroups to be excluded:
Age Range: Minimum:
Maximum

Data Source(s)

Select all electronic data sources that will be accessed for this research project. If you are unsure of the system in which data will be accessed and/or extracted, please check “Unknown.”










De-identification of Data

Select one of the following to indicate the regulatory permissions for accessing and/or extracting UPMC EMR data for this research project.




Required Storage Data





*Reminder: 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) are encrypted and password protected. Data should not be sent through e-mail, unless it is encrypted (with the key being sent separately). Data are not permitted to be stored in or transferred via personal, unprotected, unencrypted files or devices.

* Your research project may be subject to monitoring and auditing to ensure compliance with policy.

UPMC Policy HS-RS0005 Access, Acquisition and Disposition of Electronic Protected Health Information for Research Purposes
University of Pittsburgh Policy 07-02-06 Security of Electronic Medical Records – Compliance with HIPAA
University of Pittsburgh Policy 10-02-04 Computer Data Administration
University of Pittsburgh Policy 10-02-05 Computer Access and Use
University of Pittsburgh Policy 10-02-08 Use and Management of Social Security Numbers and Use of Primary ID (“UPI”) Numbers
University Policies related to Technology