Request type
* must provide value
Research study & HIPAA waiver approval
User access request (Cerner or PACS) - research & observer users only
User access request (Tableau)
Data request
Legacy archive (PaperVision)
Requestor's name
* must provide value
Requestor's email
* must provide value
Only institutional emails are accepted, i.e. GW University, GWU Hospital, and MFA email addresses.
Requestor's phone number
* must provide value
Requestor's organization
* must provide value
GW University
GWU Hospital
Medical Faculty Associates
Children's National Hospital
Other
W-2 employer
Requestor's organization, if other
* must provide value
if other selected above
Requestor's role
* must provide value
Hospital admin (C-suite)
Hospital staff
Hospital Medical Staffing Office Manager/Coordinator
Principal Investigator (PI)
Research Director
Attending
Fellow/Resident
GW Medical Student - 4th year
GW Medical Student - 3rd year
GW Medical Student - 1st/2nd year
GW Grad Student
Clinical Research Coordinator
Research Assistant
Observer from an outside institution and/or with the Medical Research Fellowship Program (MRFP)
Other
GW undergrads must coordinate with a listed role to submit a request.
Requestor's role, if other
* must provide value
if other selected above
Name of the Clinical Research Coordinator or Research Assistant associated with your research study
Email of the Clinical Research Coordinator or Research Assistant associated with your research study
Only institutional emails are accepted, i.e. GW University, GWU Hospital, and MFA email addresses.
IRB Number
* must provide value
IRB Title
* must provide value
PI's name
* must provide value
PI's email
* must provide value
Only institutional emails are accepted, i.e. GW University, GWU Hospital, and MFA email addresses.
PI's organization
* must provide value
GW University
GWU Hospital
Medical Faculty Associates
Children's National Hospital
Other
W-2 employer
Does the PI have GWU Hospital medical staff membership?Approval will only be granted to PIs who have medical staff membership.
If you answered 'No,' work with the GWU IRB Office (ohrirb@gwu.edu) to add a co-investigator that is a medical staff member of GWU Hospital.
* must provide value
Yes
No
Department (PI's)
* must provide value
Other - Not listed 3 North/Women's Services Obstetrics Acute (3N, 3 North) Coronary Care (3S, 3 South) Orthopedics Acute (4N, 4 North) Medical Acute (4S, 4 South) Surgical Acute (5N, 5 North) Oncology Acute (5S, 5 South) Neuro Trauma (6N, 6 North) Psych Acute I Adult (6S, 6 South) Accounting Acute Pain Management Center Administration Admitting, Patient Access, Registration Allergy and Immunology Ambulatory Surgery Center Anesthesiology Blood Bank Cardiac Catheterization Lab Cardiac Surgery Center Cardiology Cardiothoracic Surgery Case Management Cedar Hill Urgent Care Cedar Hill Hospital Chaplaincy Services Clinical Neurophysiology Colon and Rectal Surgery Comprehensive Bariatric Center & Surgery Comprehensive Ophthalmology Dermatology Diagnostic Radiology Education Electrophysiology Emergency Medicine (ED, ER) Employee Health Services Endocrinology Environmental and Linen Services Family Medicine/General Practice Finance, Controller, Business Analytics Food and Nutrition Foot and Ankle Surgery Gastroenterology General Surgery Geriatric Medicine Gift Shop, Starbucks, Subway Gynecologic Oncology Hand Surgery Health Information Management (HIM) Healthcare Technology Management (HTM) Heart Station Hematology Oncology Hospital Medicine Hospital Administration Human Resources (HR) Imaging Center Infection Control/Prevention Infectious Diseases Information Technology Intensive Care Unit (ICU), Critical Care Medicine Internal Medicine International Medicine/Patient Program Interventional Cardiology Interventional Radiology Labor & Delivery Services Laboratory Loss Control Marketing, Community Relations Maternal and Fetal Medicine Medical Genetics Medical Imaging Medical Library Medical Records Medical Staff Office Midwifery Neonatology (NICU), Newborn Nursery Nephrology Neurodiagnostics Neurology Neuroradiology Neurosurgery Nuclear Medicine Nursing Administration Observation Care Obstetrics and Gynecology Oncology (Cancer) Ophthalmology Optometry Oral and Maxillofacial Surgery Orthopedic Sports Medicine Orthopedic Surgery Otolaryngology (ENT) Post Anesthesia Care Unit (PACU) Pain Medicine Palliative Care Pathology Patient Experience Patient Financial Services Patient Logistics Center (PLC), Transfers Pediatric Cardiology Pediatric Endocrinology Pharmacy Physical Medicine and Rehabilitation (Physiatry, Med/Surg) Plant Operations/Facilities Plastic Surgery Podiatry Preventive Medicine Professional Development and Education Psychiatry Pulmonary Critical Care Pulmonology Quality Assurance/Management Radiology Radiation Oncology Reconstructive Plastic Surgery Rehabilitation Reproductive Endocrinology and Infertility Respiratory Services Rheumatology Risk Management Security Sleep Medicine Spine and Pain Center Spiritual Care Sports Medicine Supply Chain Operations Surgical Services (Surgery) Thoracic Surgery Transplant Institute Transplant Surgery Trauma and Critical Care Urogynecology Urology Utilization Review Vascular Surgery Women's Board Wound Care/Hyperbaric
Department (PI's), if other
* must provide value
if other selected above
Is this a modification on a previous request?
* must provide value
Yes
No
What is the modification to this study?
* must provide value
Does this study have funding (sponsorship, grants, etc.)?
* must provide value
Yes
No
Is this a radiopharmaceutical or radioactive study?
* must provide value
Yes
No
Is this a clinical device study?
* must provide value
Yes
No
Does this study involve pharmaceuticals, drugs, or combination device?
* must provide value
Yes
No
Study start date
* must provide value
Today Y-M-D industry sponsored only
Study end date
* must provide value
Today Y-M-D industry sponsored only
IRB application & protocol
DO NOT UPLOAD THE ENTIRE IRB STUDY PACKAGE. The file is too large, and your request will fail to reach our team.
* must provide value
This document must include the requestor/user's name.
IRB approval / authorization / exemption letter
DO NOT UPLOAD THE ENTIRE IRB STUDY PACKAGE. The file is too large, and your request will fail to reach our team.
* must provide value
Study contract / clinical trial agreement
Study budget / approved quote
* must provide value
industry sponsored only
Does the attachment contain the following:
* must provide value
industry sponsored only
industry sponsored only; for review by the GWUH Chief Medical Officer, CMO
Certificate of Insurance, Principal Investigator
Professional liability coverage with limits of $1M /$3M
* must provide value
industry sponsored only; for review by the GWUH and UHS Corporate
Certificate of Insurance, Each Sub-Investigator
Professional liability coverage with limits of $1M /$3M (Only Applicable if Sub-Investigators Included)
industry sponsored only; for review by the GWUH and UHS Corporate
Certificate of Insurance, Device
Products Liability coverage from the Sponsor with limits of $10M/$10M if the study involves use of a medical device
* must provide value
industry sponsored only; for review by the GWUH and UHS Corporate
Study design
* must provide value
Retrospective
Prospective
Both
Approved blank study consent form
* must provide value
Approved blank study consent form
Approved blank study consent form
Would you like to access Cerner to identify and enroll more patients in your study?
* must provide value
Yes
No
EHRs accessed for this study
* must provide value
Check all that apply.
If you do not need access to Cerner at GWUH, you do not need to submit this form.
This portal is only for Cerner at GWUH.
* must provide value
Do you only need to access Epic at the MFA?
Reach out to the MFA for Epic access. This portal is only for Cerner at GWUH.
* must provide value
Yes
No
Does your HIPAA waiver have a signature from the MFA privacy officer?
The HIPAA waiver must have this signature for studies before requesting the GWUH's privacy officer signature for Cerner. Email: privacyofficer@mfa.gwu.edu.
* must provide value
Yes
No
Must be Yes for studies using Epic at the MFA.
HIPAA waiverA HIPAA waiver is required for accessing patient charts for research without patient approval. Upload your HIPAA waiver approved by the GWU IRB office with a signature from the PI. If you're also accessing Epic, the MFA EMR, the HIPAA waiver must also have a signature from the MFA privacy officer before being submitted here, where it will be routed to the GWUH privacy officer. ___ Types of HIPAA waivers
- full authorization to PHI (full) - recruitment purposes (partial) - verifying a sufficient number of patients exist in order to justify writing a research protocol (review preparatory to research) - deceased patients (decedent)
DO NOT UPLOAD THE ENTIRE IRB STUDY PACKAGE. The file is too large, and your request will fail to reach our team.
* must provide value
Does this study gather patient names?
* must provide value
Yes
No
Provide a justification for gathering patient names.
* must provide value
Optional
Optional
Optional
Are you, the requestor, the same person as the user needing access to Cerner?
* must provide value
Yes
No
User's name
* must provide value
User's email
* must provide value
Only institutional emails are accepted, i.e. GW University, GWU Hospital, and MFA email addresses.
User's phone number
* must provide value
User's organization
* must provide value
GW University
GWU Hospital
Medical Faculty Associates
Children's National Hospital
Other
User's organization, if other
* must provide value
User's role
* must provide value
Principal Investigator (PI)
Research Director
Attending
Fellow/Resident
GW Medical Student - 4th year
GW Medical Student - 3rd year
GW Medical Student - 1st/2nd year
GW Grad Student
GW Undergrad Student
Clinical Research Coordinator
Research Assistant
Medical Staffing Office Manager/Coordinator
Observer from an outside institution and/or with the Medical Research Fellowship Program (MRFP)
Other
User's role, if other
* must provide value
if other selected above
Is the user associated with a research study?
* must provide value
Yes
No
IRB Number
* must provide value
IRB Title
* must provide value
IRB application & protocol
* must provide value
This document must include the requestor/user's name.
Is the user's name on the IRB application?
* must provide value
Yes
No
If not, provide an addendum/offer letter with the user's name added to the IRB by the Office of Human Research
DO NOT UPLOAD THE ENTIRE IRB STUDY PACKAGE. The file is too large, and your request will fail to reach our team.
* must provide value
For observers, what is the start date of their term?
* must provide value
Today Y-M-D if other selected above
For observers, what is the end date of their term?
* must provide value
Today Y-M-D if other selected above
For observers, upload their GW University acceptance letter.
* must provide value
The dates provided above must match the acceptance letter.
For observers not associated with a research study, upload a letter or email granting approval from the GWUH Medical and Privacy Officer.
* must provide value
The dates provided above must match the acceptance letter.
For observers, with whom will they be working?
* must provide value
first & last name, degree
With which medical specialty / department will the user be working?
* must provide value
Other - Not listed 3 North/Women's Services 3 South 4 North 4 South 5 North 5 South 6 North 6 South Accounting Acute Pain Management Administration Admitting/Patient Access Allergy and Immunology Ambulatory Surgery Center Anesthesiology Cardiac Catheterization Lab Cardiac Surgery Center Cardiology Cardiothoracic Surgery Case Management Cedar Hill Urgent Care Cedar Hill Hospital Clinical Neurophysiology Colon and Rectal Surgery Comprehensive Bariatric Center & Surgery Comprehensive Ophthalmology Dermatology Diagnostic Radiology Electrophysiology Emergency Medicine (ED, ER) Employee Health Endocrinology Environmental and Linen Services Family Medicine Finance, Controller, Business Analytics Food and Nutrition Foot and Ankle Surgery Gastroenterology General Surgery Geriatric Medicine Gift Shop Gynecologic Oncology Hand Surgery Health Information Management (HIM) Healthcare Technology Management (HTM) Heart Station Hematology Oncology Hospital Medicine Human Resources Infection Prevention Infectious Diseases Information Technology Intensive Care Unit (ICU), Critical Care Medicine Internal Medicine International Patient Program Interventional Cardiology Interventional Radiology Laboratory Loss Control Marketing Maternal and Fetal Medicine Medical Imaging Medical Staff Office Midwifery Neonatology Nephrology Neurodiagnostics Neurology Neuroradiology Neurosurgery Nursing Administration Obstetrics and Gynecology Optometry Oral and Maxillofacial Surgery Orthopedic Sports Medicine Orthopedic Surgery Otolaryngology (ENT) Post Anesthesia Care Unit (PACU) Pain Medicine Palliative Care Pathology Patient Experience Pediatric Cardiology Pediatric Endocrinology Pharmacy Physical Medicine and Rehabilitation Plant Operations/Facilities Plastic Surgery Podiatry Professional Development and Education Psychiatry Pulmonary Critical Care Pulmonology Quality Management Radiation Oncology Reconstructive Plastic Surgery Rehabilitation Reproductive Endocrinology and Infertility Respiratory Services Rheumatology Risk Management Security Sleep Medicine Spine and Pain Center Spiritual Care Sports Medicine Supply Chain Operations Surgical Services Thoracic Surgery Transplant Institute Transplant Surgery Trauma and Critical Care Urogynecology Urology Vascular Surgery Women's Board Wound Care/Hyperbaric
Department, if other
* must provide value
if other selected above
System needed
CernerResearch Assistant High View Only (for observers)
PACS Radiology
* must provide value
Creator
Explorer
Viewer
Provide a justification for accessing the system(s) requested.
* must provide value
Expiration date for user's research access
* must provide value
Today Y-M-D default, 3 months
GWUH IT Security and Privacy Agreement Form
Note
Only institutional emails are accepted, i.e. GW University, GWU Hospital, and MFA email addresses. Provide a domestic phone number, not an international one, if possible. Non-Employees, who do not work for GWU Hospital and work for GW University or the MFA, must provide their supervisor's employer, name, email, and phone. Signature and date must be hand-signed, not typed. It is acceptable to use the track-pad for the signature. Download
* must provide value
GWUH IT Remote Access Agreement Form
Note
Only institutional emails are accepted, i.e. GW University, GWU Hospital, and MFA email addresses. Provide a domestic phone number, not an international one, if possible. Provide their supervisor's name, signature, and affiliation. Signatures and dates must be hand-signed, not typed. It is acceptable to use the track-pad for the signature. Download
* must provide value
Purpose of the data request
* must provide value
Patient care (non-research)
Patient experience
Quality improvement
Safety
Research
Administrative, Operational
Accounting, Finance
HIM, Billing
Regulatory, Compliance
Legal
IT, Information Technology
Other
Purpose of the data request
* must provide value
Patient care (non-research)
Patient experience
Quality improvement
Safety
Research
Other
Purpose, if other
* must provide value
Is this request for an urgent regulatory audit/visit?
* must provide value
Yes
No
Timeline: If urgent, provide a specific date
Today Y-M-D
Are you a director at the hospital?
* must provide value
Yes
No
Please upload a letter (PDF of an email) of your department's director requesting and approving this data request.
* must provide value
Description of data request
* must provide value
Will the data be shared with anyone outside of the hospital?Examples: conference, journal, regulatory agency, etc.
* must provide value
Yes
No
Where will the data be shared?
* must provide value
Is this a modification to an existing data report/dashboard?
* must provide value
Yes
No
Are you already working with a hospital analyst or department?
* must provide value
Yes
No
If yes, what is the analyst's name?
* must provide value
Do you have funding for this project, such as a grant or industry sponsorship?
* must provide value
Yes
No
IRB status
* must provide value
Pre-study investigation
Study approval granted
IRB Number
* must provide value
enter 'None' if IRB number is not yet known
IRB Title
* must provide value
enter 'None' if IRB title is not yet known
Does your request require:
* must provide value
no patient data
aggregate/population level data
patient data
Only aggregated data can be pulled for your request, unless you receive IRB study approval and a signed HIPAA waiver. Please revise your request from patient specific data to population/aggregate only.
Does your request require patient names?
* must provide value
Yes
No
Provide a justification for gathering patient names.
* must provide value
Date range for data
* must provide value
Specific
Relative (calendar year/quarter)
Not applicable
Start date
* must provide value
Today Y-M-D
End date
* must provide value
Today Y-M-D
Date range, relative
* must provide value
Previous day
Previous week
Previous month
Previous quarter
Previous calendar year
Previous rolling 12-months
Current year to date
Other
Date range, relative - explain if other
* must provide value
Data output
* must provide value
Excel or text (csv/txt) file
PowerInsight report in PageCenterX
Tableau dashboard
Other
Data output, if other
* must provide value
Frequency
* must provide value
One time, ad hoc
Recurring
Frequency needed
* must provide value
Daily
Weekly
Monthly
Quarterly
Annually
Other
Frequency, if other
* must provide value
Inclusion and exclusion criteria Examples- Diagnosis or procedure codes - X < Age in Years < Y - Presented to the ED with Chest/Abdomen/Pelvis CT performed - NOT admitted to ICU - Lab value X > Y - Discharged with diagnosis abc.xyz
Attach a sample of what you think the data should look like when returned
DO NOT UPLOAD MORE THAN 8MB TOTAL FOR ALL FILES. Your request will fail to reach our team.
HIDDEN
Timeline: If urgent, provide a justification for the date provided.
Acceptable reasons: patient care, regulatory audit/visit, etc.
* must provide value
Any other special instructions or comments
Optional
Optional
Optional
List of MRNs
* must provide value