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→ Research Data Request Form
Research Data Request Form
From which DHHS office or facility is data requested?
- Select -
Commissioner’s Office
Dorothea Dix Psychiatric Center
Maine CDC
Office of Aging and Disability Services
Office of Behavioral Health
Office of Child and Family Services
Office for Family Independence
Office of MaineCare Services
Riverview Psychiatric Center
Title of Research
First Name of Research Investigator
Last Name of Research Investigator
Organization
Contact
Email
Telephone
Address
City/Town
State
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Alabama
Alaska
American Samoa
Arizona
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Armed Forces (Canada, Europe, Africa, or Middle East
Armed Forces Americas
Armed Forces Pacific
California
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Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
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Guam
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Idaho
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Maine
Marshall Islands
Maryland
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Northern Mariana Islands
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Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
Date of Request
Description of Research
Was this matter reviewed by an IRB?
Yes
No
If Yes, name of IRB
If Yes, what was the IRB determination? Please attached, below.
?
Upload IRB determination file here. File upload types are restricted for security reasons, click the ? icon. If you experience upload problems ensure there are no special characters, such as an apostrophe, in the file name.
Data Elements Requested
Names (including first and last name, or initials)
Street address
City
County
ZIP code
Elements of dates that are directly related to an individual, including birth date, admission date, discharge date, date of death
Telephone or fax numbers
Email addresses
Social security numbers
Medical record 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) addresses
Biometric identifiers, including finger and voice prints
Full-face photographs and any comparable images
Any other unique identifying number, characteristic, or code (please describe)
Does HIPAA Apply?
Yes
No
If Yes, has a HIPAA Privacy Board Waiver of Authorization been requested and/or obtained?
Yes
No
If so, please attach.
?
Upload HIPPA file. File upload types are restricted for security reasons, see ? icon. If you experience upload problems, ensure there are no special characters, such as an apostrophe, in the file name.
Consumer Authorization Obtained?
Yes
No
Other information for DHHS to consider as part of this research request:
Attach additional relevant documents in support of research request.
?
Upload additional relevant documents here. File upload types are restricted for security reasons, see ? icon. If you experience upload problems ensure there are no special characters, such as an apostrophe, in the file name.
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