Here is a sample form that may be used at your institution for clinicians to submit a request for a data search to the HIM uni

Here is a sample form that may be used at your institution for clinicians to submit a request for a data search to the HIM unit. Note: This request includes VMDB’s agreement statement because the person requesting the data may be different from the person filling out the request that is sent directly to VMDB. Click here to download the form.

REQUEST FOR ACCESS TO VTH RECORDS/DATA

REQUESTED BY: ___________________________/___________________/____________

Print Name Dept. Course No.

_______________/____________________________________________

Address Phone

If you are a CVM student? Circle one: FR SOPH JR SR

PURPOSE: ___________________________________________________________

(Teaching, Publication, Case Study, etc.)* Data collected from VTH records/data and used for publication shall have a clinician from the involved section on the paper.

List other clinician(s) to be involved in possible publication:

_____________________________________________________________________________

If data is retrieved from VMDB, Inc. (Veterinary Medical DataBase), I understand and agree that VMDB will be acknowledged within any manuscript or study. I understand that I will need to provide the VMDB with a copy of my manuscript or publication.

_________________________________/_________

Signature of Requestor/Author Date

MODALITY: ___ Record ___Imaging _____________________________________

(List type: CT, Radiology, MRI, US, NucMed)

NAME OF STUDY OR DIAGNOSIS: _______________________________________

MR# (s) ______________ ________________ _______________ ________________

Note: Client and referral veterinarian identifying data (name, phone, social security number, address, etc.) must be excluded from any reproduced records. Copies of client communications and/or accounting information may not be reproduced for research/teaching purposes. Records may not leave the building.

Twenty records may be requested at a time. Records should stay on the assigned shelf in Medical Records when not in use. During use, records may be kept in the PI’s office. If it is more convenient to work on records in another office please let office staff know.

APPROVED BY: ___________________________________________________________

VTH Chief of Staff or Section Head Date

(If a Search is needed complete the back of this form)

Complete the following ONLY if a SEARCH is needed:

Species __________________

Date Range__________________

Illinois data only [ ] yes [ ] no

Diagnosis to be searched:

_____________________________________________________________________________

What type of information will you need to abstract from the medical record?

(i.e., outcomes data, age, weight, sex, procedures performed, etc.)

_____________________________________________________________________________

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