Martini Dev

Children's Data Warehouse Form

Report Request Form

  • Provide as specific information as possible

Protected Health Information

If protected health information (PHI) will be disclosed for non-research purposes to entities outside of Children’s, please provide the reason and method for disclosure. See also Children’s Policies 1700.00 and the Guidelines For Appropriate Use.

Acknowledgement

Upon receipt, the Requestor may not use the data in a manner deviating from the declared Purpose and Use, including conveying the data to unapproved third-parties not listed on this form.

  • Storage: For any form of electronic storage, no personal computers or other equipment may be used to store and protect the requested data, unless preapproved?only media provided by Children’s may be used. Please contact the ITS department with questions. See Children’s Policies 101.00 and 1101.00.
  • Communication & Transportation: Confidential or patient-related information may only be communicated over the internet using approved encryption methods. No personal e-mail or other non-owned resources (e.g., USB drives) may be used, unless preapproved by ITS.