UT Southwestern Medical Center
Form J1
Data Collection Form
Please inform us on the data you plan to collect with this protocol. Be as thorough as possible when completing this form to avoid later modifications. You will upload this document when you complete the ClinDEN Request form after your protocol is approved.
There is a self-service tool available called i2b2 that can help define your cohort. You may also go into i2b2 directly and search to ensure that you have the correct population. Note that there are training tutorials on the main web page. There are additional training videos on YouTube and through our GPC partner, KUMC.
|Will this data leave the UT Southwestern Campus? □ Yes □ No |
|Do you have a Data Use Agreement in place? □ Yes □ No |
|Do you have a Business Associate Agreement in place? □ Yes □ No |
|Provide a written statement of your inclusion/exclusion criteria. |
|Date Range of Data | |
|HIPPA identifiers (Check all that apply) |
|□ Name |
|□ Address (all geographic subdivisions smaller than state, including street address, city county, and zip code) |
|□ All elements (except years) of dates related to an individual (including birthdate, admission date, discharge date, date of |
|death, and exact age if over 89) |
|□ Telephone numbers |
|□ Fax number |
|□ Email address |
|□ Social Security Number |
|□ Medical record number |
|□ Health plan beneficiary number |
|□ Account number |
|□ Certificate or license number |
|□ Any vehicle or other device serial number |
|□ Web URL |
|□ internet Protocol (IP) Address |
|□ Finger or voice print |
|□ Photographic image - Photographic images are not limited to images of the face. |
|□ Any other characteristic that could uniquely identify the individual |
|Demographics |
|Select all Demographic data needed |
|□ Name |□ Address |□ City |
|□ State |□ Zip |□ Phone |
|□ Email |□ Data of Birth |□ Race |
|□ Ethnicity |□ Gender |□ Language |
|□ Marital Status |□ MyChart Status |□ Vital Status |
|□ Religion |□ Tobacco Use |□ Alcohol Use |
|□ Illicit Drug Use |□ Payer Information |□ Family History |
|EMR Information |
Add as many rows as needed in any of the following tables.
Diagnosis
You may lookup ICD codes from i2b2 web client or here.
|Code |Code Type |Code Description |Source (Encounter/Billing/Problem list/All) |
| |(ICD9/ICD10) | | |
| | | | |
| | | | |
|Comments |
Procedures
The first column is either CPT or ICD procedure used for procedures that you require. CPT procedures Codes are used for Inpatient and Outpatient data. ICD Procedure Code is used for In-Patient data. You may lookup CPT Codes or through i2b2 web site
|Code |Code Type |Code Description |
| |(CPT/ICD Procedure Code) | |
| | | |
| | | |
|Comments |
Lab Results
You may lookup code from i2b2 web site or LOINC Codes web site
|LOINC Code |Code Description |
| | |
|Comments |
Medications
You may lookup ID from i2b2 web client or RxNorm
|Rx Norm ID |Medication Name |
| | |
|Comments |
|Tumor Registry |
|Provide a written description of any Tumor Registry data needed below. You may look at the information from i2b2 web client or at |
|Collaborative Stage or at NAACCR |
| |
|Clinical Notes |
|Provide a written description of any Clinical Notes needed below. |
| |
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