Page 175 - CHST Research Administration eBook 2 of 2 (Q4 2021)

Email this completed form to HIM Attention: HIMResearchRequests@childrens.com
1935 Medical District Drive Dallas, Texas 75235 (214) 456-2509
Request for Access to Medical Records for Research Purposes
Date Requested: IRB(STU) Number: ________________ Principal Investigator:
1. Is this request for access to medical record of patients consented and enrolled in the trial?
Yes (A copy of the consent form and authorization for each patient must accompany this request.)
No (Performance Site Approval (PSA) and IRB Waiver of Authorization must be provided. The waiver must specify the name or function of individuals who will be accessing the records.)
Purpose of request: _____________________________
Patients whose Medical Records are required (attach additional sheets if required): Name/MRN: Name/MRN:
Name/MRN: Name/MRN:
Name/MRN: Name/MRN:
Name/MRN: Name/MRN: Name/MRN: Name/MRN: Name/MRN: Name/MRN:
Name and affiliation of any individuals, other than requestor, being granted access (these individuals must be included by name or function on the consent form or the IRB Waiver of Consent):
a. Monitor’s name:
b. Monitor’s company:
c. Monitor’s contact number or pager:
d. Dates the monitor will need access: ______________________
e. 4 Digit Preferred PIN: __________
Updated 01/07/2019