Children's Hospital Colorado

Preparatory to Research Request Form

Preparatory to Research requests imply that you are attempting to determine the feasibility of embarking on a research project.  For example: such requests can be to determine if there are adequate numbers of patients meeting your entry criteria to warrant proceeding OR determining if the EMR records meeting those criteria contain the data items necessary for analysis.  This is NOT a request for approval to actually pursue that research or to obtain data for further analysis.  This type of request will require COMIRB approval. If you have questions, please feel free to email Dr. Jerry Clayton at jerry.clayton@childrenscolorado.org.

Note: Fields marked with * are required.

By submitting this document, the Investigator makes the following certifications:

1. Protected Health Information being sought will be used solely to prepare a research protocol or for other similar preparatory purposes such as assessing the feasibility of performing research.
2. Protected Health Information being sought is necessary for research purposes.
3. Protected Health Information utilized in the conduct of preparatory research will not leave Children's Hospital Colorado

In submitting this form, the investigator certifies that the above stipulations are correct in accordance with the Health Information Portability and Accountability Act of 1996.
The investigator also understands that any misrepresentation of the above information can result in criminal liability.

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