Step 1 of 2 - Contact and Demographic Information 50% The Research Recruitment Office can assist investigators in obtaining population numbers for grant applications, site visit number information, hypothesis generation, and recruitment assessments. Generally, these numbers are generated using information within the Indiana Network of Patient Care at Regenstrief Institute. These numbers are provided in summary format and numbers less than 10 will be indicated as < 10. In order to process your request, please complete the following 2-part form. Please know that someone from the Recruitment Office may contact you to obtain further clarifications of your data needs. Please Note: The purpose of this data pull is to give preliminary numbers for such things as grant applications and clinical trial site evaluations. This information is for research purposes only and should not be used for publications or presentations unless express permission is received from Regenstrief Institute to do so. DO NOT send Protected Health Information (ePHI) using this form. Name of Project Coordinator or Contact Person*Coordinator's/Contact's Email* Investigator's Name*Investigator's Email* Investigator's Profession*Please ChooseAdministratorNursePharmacistPhDPhysicianOtherInvestigator's Profession if other than those listed above*Investigator's School/Affiliation*Please ChooseEskenazi HealthFairbanks School of Public Health at IUPUIIndiana CTSIIU HealthIU School of DentistryIU School of Health and Rehabilitation SciencesIU School of Informatics and ComputingIU School of MedicineIU School of NursingIU School of OptometryIU School of Public and Environmental AffairsPurdue UniversityRegenstrief InstituteUniversity of Notre DameOtherInvestigator's Affiliation if other than those listed above*Department*Please ChooseAdministrationOtherDepartment*Please ChooseEpidemiologySocial and Behavioral SciencesHealth Policy and ManagementEnvironmental HealthBiostatisticsOtherDepartment*Please ChooseProject Development TeamsClinical Research CenterIndiana BiobankResearch Recruitment OfficeOtherDepartment*Please ChooseBiomedical and Applied SciencesCardiology, Operative Dentistry and Dental Public HealthEndodonticsOral Pathology, Medicine and RadiologyOral Surgery and Hospital DentistryOrthodontics and Oral Facial GeneticsPediatric DentistryPeriodontics and Allied Dental ProgramsRestorative DentistryOtherDepartment*Please ChooseHealth SciencesNutrition and DieteticsOccupational TherapyPhysical TherapyPhysician AssistantOtherDepartment*Please ChooseComputer Science and InformaticsInformation and Library ScienceIntelligent Systems EngineeringOtherDepartment*Please ChooseAnatomy and Cell BiologyAnesthesiaBiochemical and Molecular BiologyBiostatisticsCellular and Integrative PhysiologyDermatologyEmergency MedicineFamily MedicineMedical and Molecular GeneticsMedical LibrariesMedicineMicrobiology and ImmunologyNeurological SurgeryNeurologyObstetrics and GynecologyOphtlamalogyOrthopaedic SrugeryOtolaryngology - Head and Neck SurgeryPathology and Laboratory MedicinePediatricsPharmacology and ToxicologyPhysical Medicine and Health RehabiliationPsychiatryRadiation OncologyRadiology and Imaging ServicesSurgeryUrologyGraduate DivisionOtherDepartment*Please ChooseUndergraduateGraduateOtherDepartment*Please ChoosePublic AffairsHealthcare Policy and ManagementArts ManagementEnvironmental SciencesEnvironmental Sustainability StudiesOtherDepartment*Please ChooseCenter for Aging ResearchCenter for Biomedical InformaticsCenter for Health Services ResearchIndustry Research OfficeOtherDepartment*Other email address(es) to be included in correspondence, separated by semicolons (up to 3 email addresses) Study Title / Project Name*Did you run a query in i2b2 related to this feasibility request?*YesNoHow is this information being used?*Federal Grant ApplicationFoundation Grant ApplicationOther Grant ApplicationInformation for Pharmaceutical StudyHypothesis GenerationOtherIf Other, please specify:*What institutions are you requesting data from?* 1. Eskenazi Health 2. IU Health 3. Big 5 (Eskenazi Health, IU Health, St. Vincent, St. Francis & Community) 4. All INPC 5. Specific institutions not listed above Other Institutions*Please provide a list of data elements you would like to receive*e.g. - inclusion and exclusion criteria, demographics, ICD codes, service dates, lab values etc if knownRelevant Documents, if anyAccepted file types: pdf, txt, text, doc, docx, csv, xls, xlsx, ods.Relevant Documents, if anyAccepted file types: pdf, txt, text, doc, docx, csv, xls, xlsx, ods.Is there any other information important for us to know?Please Verify the anti-spam filterYou will receive a confirmation email when you click on the Submit button below. If you do not receive an email within 5 minutes of submitting a request, please email Regenstrief Data Core at email@example.com.