Emr Custom Report Request Form

JEFFERSONUNIVERSITY PHYSICIANS

EMR CUSTOM REPORT REQUEST FORM

Fax to: 215-955-0387

REQUESTOR:______DATE:______

TELEPHONE #:______

SEND REQUESTED REPORT TO:______

1.Identify the purpose/reason for request for EMR data and describe the purpose for the EMR data in detail:

 Patient Care/Quality

 Research/Study

 Other

Description: ______

2.If the purpose/reason for this request is Research/Study Related, attach a copy of the IRB Approval Letter, the OHR-4 Form(Record / Chart Review / Computer Database Research Study)and the OHR-3 Form (Request for Waiver or Authorization to Collect PHI).

3.If the purpose/reason for this request is for Patient Care/Quality or Other, please complete the following:

3.1Please list all protected health information (PHI) to be collected related to the request. This includes identifiers and health information (For example, name, MR# and phone number are identifiers; specific testing, medical history and diagnosis are health information). A list may be attached.

______

3.2Please check off those steps noted below that you intend to implement to ensure confidentiality of patient data and to protect the identifiers or codes that can be linked to identifiersfrom improper use or disclosure. (Note: Non-Jefferson sanctioned “covered devices” may not be used for the storage of identifiable subject data. See Jefferson Policy #122.35, “Wireless and Portable Device Security Policy.”)

List of identifiers will be kept in a separate location from the patient codeddata that can be linked to identifiers.
Patient data will be kept in a locked filing cabinetor desk and in a locked office.
Patient data will be kept on a password-protected, encrypted on-site computer.
Patient data will be kept on a Jefferson server. Provide specific physical and/or electronic location:
Patient data will be kept on a Jefferson-issued or –approved “covered device” as per Jefferson Policy #122.35. Specify type of “covered device” to be used:
Other (please describe):

3.3Please list the names of all individuals who will be given access to the data.

Name

/ Precise role with project

3.4Approximately how many patient records will be involved/reviewed?______

3.5Will data be sent outside of JUP?____ Yes _____ No

If no, please note that subsequent release of data outside of JUP requires approval and requestors will need to update their request.

a. If yes, where will data be sent?

b. Why is it necessary to send data outside of JUP?

c. How will data be sent? (describe actual methods and include plans for coding and/or encryption)

3.6Time period of the data to be obtained:______

(This refers to the data itself, not the time period over which you are collecting it.)

3.7How long will the data be retained, where will it be retained, how will the confidentiality of the data be maintained? ______

______

4.Indicate the date fields that are being requested for the report as well as the preferred format. Please ensure that the data fields match the OHR-3 and OHR-4 forms or the information noted in 3 above. Data fields include:

______

Requestor:______Title ______
(Signature) Date: ______

***

[JUP Administration; JUP Privacy Officer; JUP Security Officer]

Authorized By: ______Title ______Date: ______