Please complete the below form and do not leave any fields blank as missing fields may delay your request. Report requests should be submitted well in advance of your target date whenever possible. The more time the team has between receiving your request and your target date, the more likely you will receive your report by the time you need it.

* 1. Requested by:

* 2. Email:

* 3. Contact phone:

4. Alternate contact person:

5. Needed by/Target date:

6. Purpose (can choose more than one):

7. What type of request are you making:

8. Specify frequency if you will need data on a periodic basis:

9. Describe the request:
What is needed, including dates report needs to cover, why it is needed, how the data will be used, and who will use it.

10. If for research, at what stage is the project:

Please note: We can only provide de-identified aggregate data prior to IRB approval. If beyond writing proposals, please provide IRB approval number, protocol submission form & approval documentation via fax to 816-802-1114 or via email to mitrequests@cmh.edu.

11. If other than for approved research and you are requesting PHI or provider specific data beyond the scope of your job duties, provide section chief's name authorizing release of the data: