MIM Documentation “Cheat Sheet”
In order to gain access to data pulled from the Carolina Data Warehouse, certain paperwork must be filed with Medical Information Management (MIM). The following are instructions for filling out the necessary forms.
HD974
What is it? The HD974 form is a way for you to request access to protected health information for research purposes. This form has many uses at UNCHCS; the instructions below apply to CDW data requests only.
How do I fill it out? The boxes you’ll need to check depend on whether you’re requesting a fully identified, limited, or de-identified dataset. (See page 4 of the HD974 to review the definitions of “limited” and “de-identified” datasets.) If you are requesting a fully identified dataset:
1. Check the first box under section A (“I am requesting access to or disclosures of information that is individually identifiable…”).
2. Most CDW requesters then check box 2 (“I have attached a copy of the waiver of authorization…”), and then the appropriate option in section 2 (“I will provide a complete list…” / “I will access the records of fifty or more…”).
· You would only check box 1 if you individually consented every patient whose data you were requesting. This is rarely the case for a CDW request. Box 4 (on page 2) would only be used if all patients in your requested dataset are deceased.
If you are requesting a limited dataset, skip the above instructions, and only check the box under section B on page 2. If you are requesting a de-identified dataset, skip the above instructions, and only check the box under section C on the top of page 3.
For all types of datasets, fill out the information requested on page 3, being sure to list every study team member who will have access to data on the lines provided. (This includes co-investigators, research assistants, statisticians, etc.) The personnel listed here must be listed as “Study Personnel” on your approved IRB protocol. You must also attach a copy of your IRB approval letter to the HD974 prior to submission.
Have your department chair or director sign on the bottom line, then route the form back to [???].
CDW Data Access Agreement
What is it? This is an agreement by the researcher to abide by the data access and use policies set out by the CDW’s governance body. Please read through the form carefully to familiarize yourself with these policies.
How do I fill it out? Simply provide the information requested on page 2, making sure to (1) obtain your department head’s signature, and (2) list the same group of personnel listed on your HD974 (i.e., all those who will have access to the requested data) on the “Appendix” lines. Leave the CDWH Program Director Signature line blank—this will be filled by the CDW Director in when the form is processed and approved. Route the form back to [???] when complete.