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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^\d{4}-\d{4}-\d{4}-\d{3}(\d|X)$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^\d[0-9\-\ ]*\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

q3bT8z9qv7SZKEBNUvvvJx6JYRmSvqFz9UZAGVhjrBfypGDC7R3FkkeVXLACc8Mxf5civvsRugigcMVmv9NTctVS9RNpHr

Electronic Health Data or Biospecimen Request

Returning?

Please complete the request form below.

Thank you!

Y-M-D

For questions on completing this form, please contact EHR staff at < EHRCore@unmc.edu>

Electronic health data

Nebraska biobank specimen request

COVID+ biospecimen request

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Feasability assessment: potential research subject count

Consented patients who opted-in to be contacted for research

Electronic Health Record Data- NO identified data.

Electronic Health Record Data including identified data

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Serum (500 uL / sample)

Plasma (500 uL/ sample)

DNA (2ug/sample)

Feasibility counts only

Multi-center trial

Investigator-initiated trial

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Opt-in Subject Recruitment

Subject Recruitment, Other

Retrospective Study

Health Outcomes Research

Quality Improvement

Transfer of datasets to a registry

Other

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Yes

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13.1.Please tell us why there is no IRB approval or your plan of IRB application submission:

Please note: The investigator must have ethical access to the identified clinical information about the patient;

This may occur in one of three ways:
o The investigator has an existing clinical relationship with the patient; that is the information has been shared with the clinician for the primary purpose of care of the individual.
o The investigator works with a provider who has an existing clinical relationship with the patient, and the relationship between the investigator and the provider is such that the investigator could reasonably be called upon to care for the patient in a clinical setting.
o The investigator's professional responsibilities (independent of her role as a researcher) require that she has this information.

* must provide value

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Name

Medical Record numbers (MRN)

All elements of dates related to an individual (e.g. birth, admission, discharge)

Postal address information: street address, city, county, precinct, ZIP code

Telephone numbers

Fax numbers

Electronic mail addresses

Social Security numbers

Health plan beneficiary numbers

Account numbers

Certificate/license numbers

Vehicle identifiers and serial numbers, including license plate numbers

Device identifiers and serial numbers

Web Universal Resource Locators (URLs)

Internet Protocol (IP) address numbers

Any other unique identifying number/characteristic/code

Whole blood

Plasma

Serum

Virus from Nasopharyngeal swab in viral media

Tissue (please specify)

PBMCs

Stool

Other

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Yes

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Demographic data

Encounter diagnosis

Lab results,Procedures

Medications

Ob/gyn data

Social history

Other

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Yes

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15.1 Transfer of COVID+ Specimens: Which IBC are you working with?

Note: To receive any samples, you will have to include documentation from an Institutitonal Biosafety Committee (IBC) that you have a submitted and approved protocol that suggests that your institution is aware of where the samples will be used and/or stored and the personnel have the proper environment and have received the training required to handle the samples. Information on UNMC's IBC can be found on their website: unmc.edu/ibc

* must provide value

UNMC's IBC

Other IBC

N/A (For diagnostic or clinical laboratory use, only)

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Approved

In Preparation/Applying

Not Applicable

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Yes

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Y-M-D

Upload file

17. Current prices for biobank samples and the EHR identification service may be found at: https://www.unmc.edu/cctr/resources/biobank/pricing.html. We will bill the cost object provided below through the RSS Core Management System. You will receive two statements for your project one for the sample costs and one for the EHR sample identification.

17. The fees for your feasibility request, $60.00/hour, are fully subsidized by the IDeA-CTR grant, so there will be no cost to you. Please cite the National Institute of General Medical Sciences, U54 GM115458, which funds the Great Plains IDeA-CTR Network in any publications or presentations that might arise from use of this service. The content used is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

17.For billing rates of this data request, please find it at the link: https://www.unmc.edu/cctr/resources/ehr/services.html

1. I agree to comply with UNMC Policy 6045, "Privacy, Confidentiality and Information Security" and UNMC Policy 6051, "Computer Use and Electronic Information Security".

2. I certify that use of the PHI/de-identified data described above will be used only for the purpose stated above.

3. I certify that the requested data is the minimum amount of PHI/de-identified data necessary to accomplish the purposes stated above.

4. I agree to destroy the PHI/de-identified data after use.

5. I agree to store the PHI/de-identified data on secure network servers or encrypted AND password protected local computer drives or mobile devices.

If I am requesting PHI for a review preparatory to research, I certify that:

1. Review of the protected health information will be conducted solely to prepare a research protocol or for similar purposes preparatory to research;

2. I will not copy nor remove any protected health information from the University of Nebraska Medical Center campus in the course of review; and

3. The protected health information for which use or access is sought is necessary for research purposes.

* must provide value

Agree

Do not agree

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Communication Documentation

Y-M-D

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Yes

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Y-M-D

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Yes

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Y-M-D

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Upload file

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