IDEAS: Informatics Data Exchange and Acquisition System
!
Required Information
1. Your Contact Information
!
Requestor First name
(e.g., Principal Investigator, primary customer, etc)
!
Requestor Last Name
(e.g., Principal Investigator, primary customer, etc)
2. Additional Contact Information
!
Requestor Title
Administrative Staff
Research Staff
Investigator/Researcher
Resident
Fellow
Trainee (K12 or T30)
Student
Other
Other
!
Requestor Degree(s)
(select all that apply)
BA
BS
DDS
Dr.PH
Ed.D.
MD
MPH
MS
MSC
MSN
OTD
PharmD
PhD
PsyD
PT
ScD
Other
Other
!
Requestor Phone
!
Requestor Email
3. Institutional Affiliation
!
Requestor Institution Affiliation
UTHSCSA
UTSA
Christus Santa Rosa Children's Hospital
San Antonio Metro Health District
South Texas Veterans Health Care System
Southwest Foundation for Biomedical Research
University Health System
Other UT System Components
UT School of Public Health Regional Campus in San Antonio
!
Requestor Research Type
Type I
Type II
Other
Unknown
!
Service Areas Required
Administration
Biomedical Informatics
Biostatistics and Study Design
Clinical Research
Clinical Research Ethics
Community Engagement
Education and Training
Novel Clinical and Translational Methodologies
Other
Pilot and Clinical Studies
Single Point of Contact
!
Request Description
!
Date of Request
(mm/dd/yyyy)
4. Point of Contact (POC) Name (e.g., Someone that may be more accessible than the Requestor for follow up )
POC First Name
POC Last Name
POC Phone
POC Email