Center for Health Information and Research Home Center for Health Information and Research Request CHiR Services Service Request Form Select Section Home Our Team Services Student Involvement Tools and Resources Publications Contact Request CHiR Services Service request form Please review our policies and procedures before submitting this form. Requester Name/Organization Email address Phone number Due Date for Request Type of Study Research Project Health Care/Internal Operations Publication Proposal/Prep-to-Research Intervention/Evaluation Other Brief Study Purpose and Description Services Requested Aggregated Results Only Anonymous Limited Data Set Custom Data Set Data Analytics Other Data Source Requested Hospital Discharge Data Vital Records AHCCCS/Medicaid Arizona Healthcare Workforce Data Other Provider Data Other (Not Specified Above) Inclusion/Exclusion Criteria Ex. Date range, demographic, clinical restrictions, specific field names. Specify if criteria is at the individual patient level, claim level, visit level or other level Unit of Observation By claim By Patient By visit/encounter Other Special Field Definitions Definitions for any created fields such as age groupings, insurance status, etc. Analysis Methodology/Approach No data analysis is needed Data analysis is needed Output/Deliverables Deliverable 1 Deliverable 2 Deliverable 3 Study Team Members Member? Name, title, and organization Member 2 Name, title, and organization Member 3 Name, title, and organization Member 4 Name, title, and organization Member 5 Name, title, and organization Comments/Additional Information Add and additional information about this study here. If you have IRB approvals or patient consent, provide the details here or submit a copy with this form
