Page 192 - CHST Research Administration eBook 2 of 2 (Q4 2021)
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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
Dates Access Needed:
IRB(STU) Number: ________________ Principal Investigator:
1. Isthisrequestforaccesstomedicalrecordofpatientsconsentedandenrolledin 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:
Updated 1/22/2021
