Data Analytics Center Report Request Form
Please email this to firstname.lastname@example.org and in the subject line please put “Data
Analytics Center Report Request”. All items with the red * are required to be completed.
Requester Contact Information*
Email (UPHS or PSOM):
__________________________ Phone: _______________
Previous Report Name / Ticket #:
Request Approved By:
Purpose*: Please provide specific details on the objectives or abstract of your request. This will
better help us meet your specific needs.
Type of Analysis* (Please indicate the appropriate type):
Compliance, QA, Patient Care
Funded IRB Approved Research (attach IRB Approval and Protocol)
Non-funded IRB Approved Research (attach IRB Approval and Protocol)
Research Program - Is the PI performing this study for a thesis for a mentored degree
program, eg. the MPH, MSCE, MSHP, MSME, or PhD?
Expected Report Delivery Date:
Report Format (e.g. Excel, flat file, PDF, etc):
Report Frequency - Ambulatory Clinical Reports Only ______________________
One-Time Ad-Hoc Scheduled