{"xsrfToken":"192a3759684e82efa3a668f52ebf0490d9e58829_lout","branding":{"id":"11","key":"data","name":"Request CDR Data Application","portalBaseUrl":"/servicedesk/customer/portal/11"},"helpCenterBranding":{"logoId":"","isLogoAvailable":false,"helpCenterTitle":"Welcome to the Help Center","sharedPortalName":"Help Center","translations":{"en-US":{"helpCenterTitle":"Welcome to the Help Center","sharedPortalName":"Help Center","localeDisplayName":"English (United States)"}},"canEditAnnouncement":false,"siteDefaultLanguageTag":"en-US","userLanguageTag":"en-US","portalThemeColor":"#0074e0","helpCenterTitleColor":"#ffffff","useDefaultBanner":true,"isBannerAvailable":false,"hasTopBarBeenSplit":false},"portal":{"id":"11","key":"data","projectId":11046,"serviceDeskId":11,"name":"Request CDR Data Application","description":"<p>Welcome! You can raise a request for CDR Data Request using the options provided.</p>","portalBaseUrl":"/servicedesk/customer/portal/11","onlyPortal":false,"reqTypes":[{"id":"180","name":"CDR Data Application","descriptionHtml":"","callToAction":"CDR Data Application","introHtml":"","icon":11175,"iconUrl":"https://onehealthport.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/11175","groups":[36],"key":""},{"id":"176","name":"Ask a question","descriptionHtml":"","callToAction":"Ask a question","introHtml":"<p>Have a question? Submit it here.</p>","icon":11174,"iconUrl":"https://onehealthport.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/11174","groups":[],"key":""},{"id":"177","name":"Emailed request","descriptionHtml":"","callToAction":"Emailed request","introHtml":"<p>Request received from your email support channel.</p>","icon":11152,"iconUrl":"https://onehealthport.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/11152","groups":[],"key":""},{"id":"175","name":"Submit a request or incident","descriptionHtml":"","callToAction":"Submit a request or incident","introHtml":"<p>Submit a request or report a problem.</p>","icon":11165,"iconUrl":"https://onehealthport.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/11165","groups":[],"key":""}],"reqGroups":[{"id":36,"name":"General"}],"orderMapping":{"36":[180]},"kbs":{"kbEnabled":true,"kbLink":{"appLinkId":"6a1bb59e-592b-3330-85a7-875e6dfd787f","appLinkName":"System Confluence","appLinkUrl":"https://onehealthport.atlassian.net/wiki","spaceKey":"DATA","spaceName":"CDR Data Request","spaceUrl":"https://onehealthport.atlassian.net/wiki/spaces/DATA","isServer":false},"labels":[],"projectKey":"DATA","serviceDeskId":11,"kbLinkDomainURLs":["https://onehealthport.atlassian.net"]},"createPermission":true,"portalAnnouncement":{"portalId":11,"canEditAnnouncement":false,"canAdministerProject":false,"portalProjectKey":"DATA","userLanguageHeader":"","userLanguageMessageWiki":"","defaultLanguageHeader":"","defaultLanguageMessage":"","defaultLanguageDisplayName":"English (United States)","isUsingLanguageSupport":false,"translations":{}},"canViewCreateRequestForm":true,"isProjectSimplified":false,"mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIyYzFjNmRlMy1lMjViLTQxMTctYTFjNy04NWRiZGFmYjE4ZDMiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpjb2xsZWN0aW9uOnVwbG9hZC1wcm9qZWN0LTExMDQ2IjpbInJlYWQiLCJjcmVhdGUiLCJ1cGRhdGUiXSwidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE3MzQ3OTczODIsIm5iZiI6MTczNDc5NjE4Mn0.78d5NPafL19OCJfC3vOfSiw2Ef78Am0GrD2frw3vI8s","targetCollection":"upload-project-11046","endpointUrl":"https://api.media.atlassian.com","clientId":"2c1c6de3-e25b-4117-a1c7-85dbdafb18d3","tokenDurationInMins":20}},"reqCreate":{"id":180,"projectId":11046,"form":{"name":"CDR Data Application","descriptionHtml":"","callToAction":"CDR Data Application","intro":"","instructions":"","icon":11175,"iconUrl":"https://onehealthport.atlassian.net/rest/servicedeskapi/requesttype/icon/type/SD_REQTYPE/id/11175","key":""},"fields":[{"fieldType":"text","fieldId":"email","fieldConfigId":"","label":"Email confirmation to","description":"","descriptionHtml":"","required":true,"displayed":true,"presetValues":[]},{"fieldType":"text","jiraFieldType":"summary","fieldId":"summary","fieldConfigId":"","label":"Summary","description":"","descriptionHtml":"","required":true,"displayed":false,"presetValues":["Clinical Data Repository Data Request Form"]}],"userOrganisations":[],"canBrowseUsers":false,"requestCreateBaseUrl":"/servicedesk/customer/portal/11/create/180","requestValidateBaseUrl":"/servicedesk/customer/portal/11/validate/180","calendarParams":{"firstDay":0,"date":"2024-12-21T07:49:43-0800","useISO8601WeekNumbers":false,"dateIfFormat":"%m/%d/%y","dateTimeIfFormat":"%m/%d/%y %I:%M %p","timeFormat":"12"},"kbs":{"kbEnabled":true,"kbLink":{"appLinkId":"6a1bb59e-592b-3330-85a7-875e6dfd787f","appLinkName":"System Confluence","appLinkUrl":"https://onehealthport.atlassian.net/wiki","spaceKey":"DATA","spaceName":"CDR Data Request","spaceUrl":"https://onehealthport.atlassian.net/wiki/spaces/DATA","isServer":false},"labels":[],"projectKey":"DATA","serviceDeskId":11,"kbLinkDomainURLs":["https://onehealthport.atlassian.net"]},"canRaiseOnBehalf":false,"canSignupCustomers":false,"canCreateAttachments":true,"attachmentRequiredField":false,"hasGroups":true,"canSubmitWithEmailAddress":false,"showRecaptcha":false,"siteKey":"","mediaApiUploadInformation":{"token":"eyJhbGciOiJIUzI1NiJ9.eyJpc3MiOiIyYzFjNmRlMy1lMjViLTQxMTctYTFjNy04NWRiZGFmYjE4ZDMiLCJhY2Nlc3MiOnsidXJuOmZpbGVzdG9yZTpjb2xsZWN0aW9uOnVwbG9hZC1wcm9qZWN0LTExMDQ2IjpbInJlYWQiLCJjcmVhdGUiLCJ1cGRhdGUiXSwidXJuOmZpbGVzdG9yZTp1cGxvYWQ6KiI6WyJyZWFkIiwiY3JlYXRlIiwidXBkYXRlIl0sInVybjpmaWxlc3RvcmU6Y2h1bms6KiI6WyJyZWFkIiwiY3JlYXRlIl19LCJleHAiOjE3MzQ3OTczODMsIm5iZiI6MTczNDc5NjE4M30.0Prh1ukdqR0N73EPgPNktDsZ4tdjwxeB7DrguCKjN48","targetCollection":"upload-project-11046","endpointUrl":"https://api.media.atlassian.com","clientId":"2c1c6de3-e25b-4117-a1c7-85dbdafb18d3","tokenDurationInMins":20},"hasProformaForm":true,"proformaTemplateForm":{"id":3,"updated":"2023-11-08T21:21:08.400785Z","publish":{"jira":{"submitOnCreate":false,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[180],"submitOnCreate":false,"validateOnCreate":true}},"design":{"settings":{"templateId":3,"name":"DUA EXHIBIT A: APPROVED CDR DATA APPLICATION(S) FORM","submit":{"lock":false,"pdf":true},"language":"en-US","templateFormUuid":"1a4bbba8-d706-4dd5-8fb3-34f9d4dc8527"},"layout":[{"version":1,"type":"doc","content":[]},{"version":1,"type":"doc","content":[{"type":"paragraph","content":[{"type":"text","text":"Instructions:","marks":[{"type":"strong"}]},{"type":"text","text":" "},{"type":"text","text":"This Data Application form and all required attachments must be submitted to OneHealthPort. Final decisions about data access cannot be made until the full application is received. OneHealthPort will provide you with a response to your request within 30 days. If your data request is approved, OneHealthPort will work with you to further qualify your data request and work toward a Data Use Agreement. ","marks":[{"type":"em"}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Section A: Requestor Information","marks":[{"type":"strong"}]}]},{"type":"paragraph","content":[{"type":"text","text":"IMPORTANT!","marks":[{"type":"strong"},{"type":"textColor","attrs":{"color":"#ff5630"}}]},{"type":"text","text":" The individual completing the application must have the authority to submit and attest to the application on behalf of the submitting organization."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":2},"localId":"9507fc97-0760-43fa-807f-50599435c391"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":41},"localId":"7c0fc747-81ae-4471-90cd-619951d2f11f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":5},"localId":"947bd115-fd18-42bd-864f-0ca27ea0297a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":6},"localId":"65db546f-4b21-48e1-9b18-fc3f3c5f75b6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":38},"localId":"1995b6a6-9171-4fc5-972b-b581d28b18b6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":37},"localId":"126d42f5-5260-470c-a962-11e72968819d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":39},"localId":"2e4df05f-820d-41cd-b858-20a98859761e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":40},"localId":"d72e33b9-c9b3-4bf2-8ce5-caece2b46b8d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":7},"localId":"a288c379-0e24-49ac-90aa-6a92baa94e12"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":8},"localId":"5042a982-d8f3-4a50-b526-643892c27a65"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":9},"localId":"cbb30d64-a2a9-4bf1-b8b0-51df222b7c39"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":11},"localId":"c3858d6d-90f0-4ce4-892b-9d10e27339ee"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Section B: Data Request Information","marks":[{"type":"strong"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":12},"localId":"7709b28f-ec08-4acc-84c4-85bfb8e5aeec"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":47},"localId":"4ded2e97-cbb1-4740-8947-03f034c6404d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":13},"localId":"b2b1fa7a-8f67-4b76-aa49-d648b9ea2327"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":64},"localId":"fe8b4200-5cd1-4eb3-9373-993bc88831ce"}},{"type":"paragraph","content":[{"type":"text","text":"Refer to "},{"type":"text","text":"§164.514","marks":[{"type":"link","attrs":{"href":"https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.514"}}]},{"type":"text","text":" and "},{"type":"text","text":"WA OCIO","marks":[{"type":"link","attrs":{"href":"https://ocio.wa.gov/"}}]},{"type":"text","text":" data classification for deidentification standards."}]},{"type":"paragraph","content":[]},{"type":"paragraph","content":[{"type":"text","text":"6) Select the data you will use for your project. Data elements can be found on the Clinical Data Repository Program "},{"type":"text","text":"website","marks":[{"type":"link","attrs":{"href":"https://www.onehealthport.com/clinical-data-repository-data-products"}},{"type":"underline"}]},{"type":"text","text":".","marks":[{"type":"underline"}]},{"type":"text","text":" Select all that apply."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":52},"localId":"4965e2be-c891-49b4-8a8f-0012615e2755"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":53},"localId":"c4b15c94-58ff-4fce-aadf-37ac424f059a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":54},"localId":"a543833c-65b6-4a06-8156-a401a2f35921"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":55},"localId":"5ec291e6-daea-4583-9d2a-d45a17789468"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":57},"localId":"0d9e80af-b766-48ca-bb13-2671fb0d97bc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":16},"localId":"926b06a9-3f6d-4756-9622-1e9fc643b891"}},{"type":"paragraph","content":[{"type":"text","text":"Details about the CDR data and data products can be found on the Clinical Data Repository Program "},{"type":"text","text":"website","marks":[{"type":"link","attrs":{"href":"https://www.onehealthport.com/clinical-data-repository-data-products"}},{"type":"underline"}]},{"type":"text","text":". "}]},{"type":"paragraph","content":[]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":17},"localId":"dc002d54-6f0f-4374-94cf-6b01dade02a0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":18},"localId":"2df431bb-aa60-4fac-9100-16acaad6c845"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":21},"localId":"90129dd0-3082-4728-b972-7662968e9610"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":22},"localId":"1ef4b56a-16a6-42fb-ab03-a0d719670353"}},{"type":"paragraph","content":[{"type":"text","text":"If "},{"type":"text","text":"End Date","marks":[{"type":"em"}]},{"type":"text","text":" is more than one year from "},{"type":"text","text":"Start Date","marks":[{"type":"em"}]},{"type":"text","text":", provide rationale for the timeframe of your data needs."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":67},"localId":"a85f28e0-9a23-4374-a3c8-753270d90c10"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":23},"localId":"9eb7c309-0abe-411d-b223-41868dbe71f2"}},{"type":"paragraph","content":[{"type":"text","text":"If a subscription is selected, OneHealthPort will provide a Certificate of Continued Need and Compliance that is required for the application."}]},{"type":"paragraph","content":[{"type":"text","text":" "}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":24},"localId":"08229b27-a55c-4fdf-8d57-b3db592324ab"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":25},"localId":"07c62580-124f-4efb-b0eb-014aa0dc124b"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Section C: Confidentiality and Security of Dataset","marks":[{"type":"strong"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":27},"localId":"9c7a405c-f4ac-4c8c-8226-39422fd24961"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":28},"localId":"fc3b753f-83f5-46fa-99b3-b895319bdc8d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":29},"localId":"fc19d83e-b45f-4fd2-ae4a-16162c44d78b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":68},"localId":"f7980cb9-c96f-45e5-81b1-497ba720e5c1"}},{"type":"paragraph","content":[{"type":"text","text":"By submitting this data request form, I attest to 1) ","marks":[{"type":"strong"}]},{"type":"text","text":"the accuracy of the information provided","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":", 2) ","marks":[{"type":"strong"}]},{"type":"text","text":"my organization’s ability to meet data privacy and security requirements","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":", and 3) ","marks":[{"type":"strong"}]},{"type":"text","text":"my authority to act on behalf of the organization seeking CDR data for the purposes described in this application","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":".","marks":[{"type":"strong"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":50},"localId":"fed06ca5-e30d-440d-87fa-32ab37a11630"}}]}],"conditions":{},"sections":{"1":{"name":"Section A: Requestor Information","conditions":[]},"2":{"name":"Section B: Data Request Information","conditions":[]},"3":{"name":"Section C: Confidentiality and Security of Dataset","conditions":[]}},"questions":{"67":{"type":"rt","label":"","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"12":{"type":"cm","label":"3) For what purpose are you requesting data?","description":"","validation":{"rq":true,"mns":1,"mxs":1},"choices":[{"id":"1","label":"Patient Care","other":false},{"id":"2","label":"Population Health","other":false},{"id":"9","label":"Care Quality","other":false},{"id":"3","label":"Public Health","other":false},{"id":"5","label":"Patient Consumer Access","other":false},{"id":"8","label":"Community Social Service","other":false},{"id":"10","label":"Research with IRB approval (OneHealthPort will collect a copy of your approved or exempt IRB determination status notification)","other":false},{"id":"7","label":"Research not subject to IRB review","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"8":{"type":"ts","label":"Phone Number:","description":"","validation":{"rq":true,"rgx":{"p":"^(?=.{1,30}$)\\s*(?:\\+?(\\d{1,3}))?([-.(]*(\\d{3})[-.)]*)?((\\d{3})[-.]*(\\d{2,4})(?:[-.x]*(\\d+))?)\\s*$","m":"+1-(800)-123-4567"}},"choices":[],"questionKey":""},"23":{"type":"cm","label":"10) Do you anticipate this is a one-time request or an ongoing request?","description":"","validation":{"rq":true,"mxs":1},"choices":[{"id":"1","label":"One-time request for a single dataset","other":false},{"id":"2","label":"Monthly subscription","other":false},{"id":"3","label":"Quarterly subscription","other":false},{"id":"4","label":"Annual subscription","other":false}],"questionKey":""},"40":{"type":"ts","label":"Zip:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"13":{"type":"rt","label":"4) Describe your project and how you will use the CDR data. Provide enough detail so that reviewers will be able to assess the suitability of the Data Application request such as project goals and intended audience. ","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"5":{"type":"tl","label":"Organization:","description":"","validation":{"rq":true},"jiraField":"customfield_12030","questionKey":""},"21":{"type":"da","label":"9) Provide the timeframe for your data needs:","description":"Start Date:","validation":{"rq":true,"mnd":"2017-05-01"},"choices":[],"questionKey":""},"54":{"type":"cm","label":"Patient","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Advance Directives","other":false},{"id":"2","label":"Data Sponsor","other":false},{"id":"3","label":"Patients Demographics","other":false},{"id":"4","label":"Patient Email","other":false},{"id":"5","label":"Patient Employer","other":false},{"id":"6","label":"Patient Ethnicity","other":false},{"id":"7","label":"Patient Home Address","other":false},{"id":"8","label":"Patient Language","other":false},{"id":"9","label":"Patient Occupation","other":false},{"id":"10","label":"Patient Phone Number","other":false},{"id":"11","label":"Patient Race","other":false}],"questionKey":""},"57":{"type":"cm","label":"CCD Document Data","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"CCD Header","other":false},{"id":"2","label":"Confidentiality Code","other":false},{"id":"3","label":"Place of Service","other":false}],"questionKey":""},"47":{"type":"rt","label":"If you checked Research, not subject to IRB review, describe why data request is not subject to IRB review.","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"27":{"type":"cm","label":"12) Data Destruction: ","description":"Per the Data Use Agreement (DUA), the data recipient must provide evidence to OneHealthPort that the data has been destroyed after the project has been completed. A signed Certificate of Project Completion & Data Destruction must be provided within 10 days of the end of the project, or termination of the DUA, whichever is sooner. Check the following box to indicate you will abide with these data destruction requirements.","validation":{"rq":true},"choices":[{"id":"1","label":"I agree to the data destruction requirements.","other":false}],"questionKey":""},"18":{"type":"ts","label":"If yes, indicate number of patients:","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"7":{"type":"tl","label":"Email:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"52":{"type":"cm","label":"Clinical Data","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Administered Medications","other":false},{"id":"2","label":"Allergen","other":false},{"id":"3","label":"Allergic Agent","other":false},{"id":"4","label":"Allergic Reaction Descriptions","other":false},{"id":"5","label":"Allergic Reaction severity","other":false},{"id":"6","label":"Drug Codes","other":false},{"id":"7","label":"Family History","other":false},{"id":"8","label":"Immunizations","other":false},{"id":"9","label":"Lab Tests and Results","other":false},{"id":"10","label":"Plan of Future Treatment","other":false},{"id":"11","label":"Prescribed Medications","other":false},{"id":"12","label":"Prescribed Information","other":false},{"id":"13","label":"Problems","other":false},{"id":"14","label":"Procedures","other":false},{"id":"15","label":"Progress Notes","other":false},{"id":"16","label":"Reason for Visit","other":false},{"id":"17","label":"Rx Generic Substitution","other":false},{"id":"18","label":"Social History","other":false},{"id":"19","label":"Vital Signs","other":false},{"id":"20","label":"Functional Status","other":false},{"id":"21","label":"Medical Equipment","other":false}],"questionKey":""},"28":{"type":"rt","label":"13) Briefly describe your plan to protect the information in accordance with HIPAA, OCIO 141.10 or other state or federal regulations:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"11":{"type":"cm","label":"2) Type of Organization, select all that apply:","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Hospital, clinic, or other delivery system","other":false},{"id":"2","label":"Health Plan","other":false},{"id":"3","label":"Research entity","other":false},{"id":"4","label":"Federal, State or Local Government Agency","other":false},{"id":"9","label":"Out-of-State Agency","other":false},{"id":"6","label":"Private company/Corporation","other":false},{"id":"7","label":"Non-profit agency","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"9":{"type":"cd","label":"1) Your role in the organization (select one):","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Provider","other":false},{"id":"2","label":"Administrator","other":false},{"id":"3","label":"Analytics, Actuarial, or Population Health Staff","other":false},{"id":"4","label":"Researcher","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"22":{"type":"da","label":"","description":"End Date:","validation":{"rq":false},"choices":[],"questionKey":""},"55":{"type":"cm","label":"Practitioner","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Author of CCD","other":false},{"id":"2","label":"Custodial Organization","other":false},{"id":"3","label":"Facility Data","other":false},{"id":"4","label":"Practitioner ID Information","other":false},{"id":"5","label":"Primary Care Practitioner","other":false},{"id":"6","label":"Visited Clinic Data","other":false}],"questionKey":""},"50":{"type":"tl","label":"Type name below as signature","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"37":{"type":"ts","label":"City:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"68":{"type":"cm","label":"15) Requestor is also required to complete a List of Authorized Data Users and submit a Confidentiality Agreement signed by each user. OneHealthPort will provide these documents to the data requestor and collect all signed documents.","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"I agree to provide a Confidentiality Agreement executed by each authorized data user prior to accessing the CDR data.","other":false}],"questionKey":""},"24":{"type":"cm","label":"11) Will the data be linked with existing organizational patient data, such as with EHR data?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Yes (describe below)","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"16":{"type":"cm","label":"7) Select the type of data product you are requesting (check only one option):","description":"","validation":{"rq":true,"mns":0,"mxs":1},"choices":[{"id":"1","label":"Custom Data Extract ","other":false},{"id":"2","label":"Custom Analytic Report","other":false}],"questionKey":""},"6":{"type":"tl","label":"Address 1:","description":"","validation":{"rq":true},"jiraField":"customfield_12083","questionKey":""},"39":{"type":"ts","label":"State:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"17":{"type":"cm","label":"8) Do you have a list of patients for whom you are requesting data?","description":"","validation":{"rq":true,"mxs":1},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"25":{"type":"rt","label":"Describe what data will be linked to the CDR information:","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"64":{"type":"cm","label":"5) Are you requesting identified or deidentified data:","description":"","validation":{"rq":true,"mns":0,"mxs":1},"choices":[{"id":"1","label":"Identified","other":false},{"id":"2","label":"Deidentified","other":false}],"questionKey":""},"53":{"type":"cm","label":"Insurance","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Insurance Contact Info","other":false},{"id":"2","label":"Patient's Insurance","other":false}],"questionKey":""},"2":{"type":"tl","label":"Requestor Name:","description":"","validation":{"rq":true},"jiraField":"customfield_12048","questionKey":""},"38":{"type":"tl","label":"Address 2:","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"29":{"type":"cm","label":"14) Do you plan to share the CDR data or derived data products with anyone other than the authorized data users from your organization?","description":"","validation":{"rq":true},"choices":[{"id":"3","label":"Yes (OneHealthPort will provide a Recipient Data Output that is required for the application)","other":false},{"id":"4","label":"No","other":false}],"questionKey":""},"41":{"type":"tl","label":"Requestor Title:","description":"","validation":{"rq":true},"choices":[],"questionKey":""}}},"uuid":"1a4bbba8-d706-4dd5-8fb3-34f9d4dc8527"},"proforma":{"formExists":true,"formValid":true,"formTemplateData":{"id":3,"updated":"2023-11-08T21:21:08.400785Z","publish":{"jira":{"submitOnCreate":false,"validateOnCreate":true},"portal":{"portalRequestTypeIds":[180],"submitOnCreate":false,"validateOnCreate":true}},"design":{"settings":{"templateId":3,"name":"DUA EXHIBIT A: APPROVED CDR DATA APPLICATION(S) FORM","submit":{"lock":false,"pdf":true},"language":"en-US","templateFormUuid":"1a4bbba8-d706-4dd5-8fb3-34f9d4dc8527"},"layout":[{"version":1,"type":"doc","content":[]},{"version":1,"type":"doc","content":[{"type":"paragraph","content":[{"type":"text","text":"Instructions:","marks":[{"type":"strong"}]},{"type":"text","text":" "},{"type":"text","text":"This Data Application form and all required attachments must be submitted to OneHealthPort. Final decisions about data access cannot be made until the full application is received. OneHealthPort will provide you with a response to your request within 30 days. If your data request is approved, OneHealthPort will work with you to further qualify your data request and work toward a Data Use Agreement. ","marks":[{"type":"em"}]}]},{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Section A: Requestor Information","marks":[{"type":"strong"}]}]},{"type":"paragraph","content":[{"type":"text","text":"IMPORTANT!","marks":[{"type":"strong"},{"type":"textColor","attrs":{"color":"#ff5630"}}]},{"type":"text","text":" The individual completing the application must have the authority to submit and attest to the application on behalf of the submitting organization."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":2},"localId":"9507fc97-0760-43fa-807f-50599435c391"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":41},"localId":"7c0fc747-81ae-4471-90cd-619951d2f11f"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":5},"localId":"947bd115-fd18-42bd-864f-0ca27ea0297a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":6},"localId":"65db546f-4b21-48e1-9b18-fc3f3c5f75b6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":38},"localId":"1995b6a6-9171-4fc5-972b-b581d28b18b6"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":37},"localId":"126d42f5-5260-470c-a962-11e72968819d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":39},"localId":"2e4df05f-820d-41cd-b858-20a98859761e"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":40},"localId":"d72e33b9-c9b3-4bf2-8ce5-caece2b46b8d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":7},"localId":"a288c379-0e24-49ac-90aa-6a92baa94e12"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":8},"localId":"5042a982-d8f3-4a50-b526-643892c27a65"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":9},"localId":"cbb30d64-a2a9-4bf1-b8b0-51df222b7c39"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":11},"localId":"c3858d6d-90f0-4ce4-892b-9d10e27339ee"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Section B: Data Request Information","marks":[{"type":"strong"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":12},"localId":"7709b28f-ec08-4acc-84c4-85bfb8e5aeec"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":47},"localId":"4ded2e97-cbb1-4740-8947-03f034c6404d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":13},"localId":"b2b1fa7a-8f67-4b76-aa49-d648b9ea2327"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":64},"localId":"fe8b4200-5cd1-4eb3-9373-993bc88831ce"}},{"type":"paragraph","content":[{"type":"text","text":"Refer to "},{"type":"text","text":"§164.514","marks":[{"type":"link","attrs":{"href":"https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.514"}}]},{"type":"text","text":" and "},{"type":"text","text":"WA OCIO","marks":[{"type":"link","attrs":{"href":"https://ocio.wa.gov/"}}]},{"type":"text","text":" data classification for deidentification standards."}]},{"type":"paragraph","content":[]},{"type":"paragraph","content":[{"type":"text","text":"6) Select the data you will use for your project. Data elements can be found on the Clinical Data Repository Program "},{"type":"text","text":"website","marks":[{"type":"link","attrs":{"href":"https://www.onehealthport.com/clinical-data-repository-data-products"}},{"type":"underline"}]},{"type":"text","text":".","marks":[{"type":"underline"}]},{"type":"text","text":" Select all that apply."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":52},"localId":"4965e2be-c891-49b4-8a8f-0012615e2755"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":53},"localId":"c4b15c94-58ff-4fce-aadf-37ac424f059a"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":54},"localId":"a543833c-65b6-4a06-8156-a401a2f35921"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":55},"localId":"5ec291e6-daea-4583-9d2a-d45a17789468"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":57},"localId":"0d9e80af-b766-48ca-bb13-2671fb0d97bc"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":16},"localId":"926b06a9-3f6d-4756-9622-1e9fc643b891"}},{"type":"paragraph","content":[{"type":"text","text":"Details about the CDR data and data products can be found on the Clinical Data Repository Program "},{"type":"text","text":"website","marks":[{"type":"link","attrs":{"href":"https://www.onehealthport.com/clinical-data-repository-data-products"}},{"type":"underline"}]},{"type":"text","text":". "}]},{"type":"paragraph","content":[]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":17},"localId":"dc002d54-6f0f-4374-94cf-6b01dade02a0"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":18},"localId":"2df431bb-aa60-4fac-9100-16acaad6c845"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":21},"localId":"90129dd0-3082-4728-b972-7662968e9610"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":22},"localId":"1ef4b56a-16a6-42fb-ab03-a0d719670353"}},{"type":"paragraph","content":[{"type":"text","text":"If "},{"type":"text","text":"End Date","marks":[{"type":"em"}]},{"type":"text","text":" is more than one year from "},{"type":"text","text":"Start Date","marks":[{"type":"em"}]},{"type":"text","text":", provide rationale for the timeframe of your data needs."}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":67},"localId":"a85f28e0-9a23-4374-a3c8-753270d90c10"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":23},"localId":"9eb7c309-0abe-411d-b223-41868dbe71f2"}},{"type":"paragraph","content":[{"type":"text","text":"If a subscription is selected, OneHealthPort will provide a Certificate of Continued Need and Compliance that is required for the application."}]},{"type":"paragraph","content":[{"type":"text","text":" "}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":24},"localId":"08229b27-a55c-4fdf-8d57-b3db592324ab"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":25},"localId":"07c62580-124f-4efb-b0eb-014aa0dc124b"}}]},{"version":1,"type":"doc","content":[{"type":"heading","attrs":{"level":2},"content":[{"type":"text","text":"Section C: Confidentiality and Security of Dataset","marks":[{"type":"strong"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":27},"localId":"9c7a405c-f4ac-4c8c-8226-39422fd24961"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":28},"localId":"fc3b753f-83f5-46fa-99b3-b895319bdc8d"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":29},"localId":"fc19d83e-b45f-4fd2-ae4a-16162c44d78b"}},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":68},"localId":"f7980cb9-c96f-45e5-81b1-497ba720e5c1"}},{"type":"paragraph","content":[{"type":"text","text":"By submitting this data request form, I attest to 1) ","marks":[{"type":"strong"}]},{"type":"text","text":"the accuracy of the information provided","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":", 2) ","marks":[{"type":"strong"}]},{"type":"text","text":"my organization’s ability to meet data privacy and security requirements","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":", and 3) ","marks":[{"type":"strong"}]},{"type":"text","text":"my authority to act on behalf of the organization seeking CDR data for the purposes described in this application","marks":[{"type":"em"},{"type":"strong"}]},{"type":"text","text":".","marks":[{"type":"strong"}]}]},{"type":"extension","attrs":{"extensionKey":"question","extensionType":"com.thinktilt.proforma","layout":"default","parameters":{"id":50},"localId":"fed06ca5-e30d-440d-87fa-32ab37a11630"}}]}],"conditions":{},"sections":{"1":{"name":"Section A: Requestor Information","conditions":[]},"2":{"name":"Section B: Data Request Information","conditions":[]},"3":{"name":"Section C: Confidentiality and Security of Dataset","conditions":[]}},"questions":{"67":{"type":"rt","label":"","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"12":{"type":"cm","label":"3) For what purpose are you requesting data?","description":"","validation":{"rq":true,"mns":1,"mxs":1},"choices":[{"id":"1","label":"Patient Care","other":false},{"id":"2","label":"Population Health","other":false},{"id":"9","label":"Care Quality","other":false},{"id":"3","label":"Public Health","other":false},{"id":"5","label":"Patient Consumer Access","other":false},{"id":"8","label":"Community Social Service","other":false},{"id":"10","label":"Research with IRB approval (OneHealthPort will collect a copy of your approved or exempt IRB determination status notification)","other":false},{"id":"7","label":"Research not subject to IRB review","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"8":{"type":"ts","label":"Phone Number:","description":"","validation":{"rq":true,"rgx":{"p":"^(?=.{1,30}$)\\s*(?:\\+?(\\d{1,3}))?([-.(]*(\\d{3})[-.)]*)?((\\d{3})[-.]*(\\d{2,4})(?:[-.x]*(\\d+))?)\\s*$","m":"+1-(800)-123-4567"}},"choices":[],"questionKey":""},"23":{"type":"cm","label":"10) Do you anticipate this is a one-time request or an ongoing request?","description":"","validation":{"rq":true,"mxs":1},"choices":[{"id":"1","label":"One-time request for a single dataset","other":false},{"id":"2","label":"Monthly subscription","other":false},{"id":"3","label":"Quarterly subscription","other":false},{"id":"4","label":"Annual subscription","other":false}],"questionKey":""},"40":{"type":"ts","label":"Zip:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"13":{"type":"rt","label":"4) Describe your project and how you will use the CDR data. Provide enough detail so that reviewers will be able to assess the suitability of the Data Application request such as project goals and intended audience. ","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"5":{"type":"tl","label":"Organization:","description":"","validation":{"rq":true},"jiraField":"customfield_12030","questionKey":""},"21":{"type":"da","label":"9) Provide the timeframe for your data needs:","description":"Start Date:","validation":{"rq":true,"mnd":"2017-05-01"},"choices":[],"questionKey":""},"54":{"type":"cm","label":"Patient","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Advance Directives","other":false},{"id":"2","label":"Data Sponsor","other":false},{"id":"3","label":"Patients Demographics","other":false},{"id":"4","label":"Patient Email","other":false},{"id":"5","label":"Patient Employer","other":false},{"id":"6","label":"Patient Ethnicity","other":false},{"id":"7","label":"Patient Home Address","other":false},{"id":"8","label":"Patient Language","other":false},{"id":"9","label":"Patient Occupation","other":false},{"id":"10","label":"Patient Phone Number","other":false},{"id":"11","label":"Patient Race","other":false}],"questionKey":""},"57":{"type":"cm","label":"CCD Document Data","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"CCD Header","other":false},{"id":"2","label":"Confidentiality Code","other":false},{"id":"3","label":"Place of Service","other":false}],"questionKey":""},"47":{"type":"rt","label":"If you checked Research, not subject to IRB review, describe why data request is not subject to IRB review.","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"27":{"type":"cm","label":"12) Data Destruction: ","description":"Per the Data Use Agreement (DUA), the data recipient must provide evidence to OneHealthPort that the data has been destroyed after the project has been completed. A signed Certificate of Project Completion & Data Destruction must be provided within 10 days of the end of the project, or termination of the DUA, whichever is sooner. Check the following box to indicate you will abide with these data destruction requirements.","validation":{"rq":true},"choices":[{"id":"1","label":"I agree to the data destruction requirements.","other":false}],"questionKey":""},"18":{"type":"ts","label":"If yes, indicate number of patients:","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"7":{"type":"tl","label":"Email:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"52":{"type":"cm","label":"Clinical Data","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Administered Medications","other":false},{"id":"2","label":"Allergen","other":false},{"id":"3","label":"Allergic Agent","other":false},{"id":"4","label":"Allergic Reaction Descriptions","other":false},{"id":"5","label":"Allergic Reaction severity","other":false},{"id":"6","label":"Drug Codes","other":false},{"id":"7","label":"Family History","other":false},{"id":"8","label":"Immunizations","other":false},{"id":"9","label":"Lab Tests and Results","other":false},{"id":"10","label":"Plan of Future Treatment","other":false},{"id":"11","label":"Prescribed Medications","other":false},{"id":"12","label":"Prescribed Information","other":false},{"id":"13","label":"Problems","other":false},{"id":"14","label":"Procedures","other":false},{"id":"15","label":"Progress Notes","other":false},{"id":"16","label":"Reason for Visit","other":false},{"id":"17","label":"Rx Generic Substitution","other":false},{"id":"18","label":"Social History","other":false},{"id":"19","label":"Vital Signs","other":false},{"id":"20","label":"Functional Status","other":false},{"id":"21","label":"Medical Equipment","other":false}],"questionKey":""},"28":{"type":"rt","label":"13) Briefly describe your plan to protect the information in accordance with HIPAA, OCIO 141.10 or other state or federal regulations:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"11":{"type":"cm","label":"2) Type of Organization, select all that apply:","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Hospital, clinic, or other delivery system","other":false},{"id":"2","label":"Health Plan","other":false},{"id":"3","label":"Research entity","other":false},{"id":"4","label":"Federal, State or Local Government Agency","other":false},{"id":"9","label":"Out-of-State Agency","other":false},{"id":"6","label":"Private company/Corporation","other":false},{"id":"7","label":"Non-profit agency","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"9":{"type":"cd","label":"1) Your role in the organization (select one):","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Provider","other":false},{"id":"2","label":"Administrator","other":false},{"id":"3","label":"Analytics, Actuarial, or Population Health Staff","other":false},{"id":"4","label":"Researcher","other":false},{"id":"0","label":"Other...","other":true}],"questionKey":""},"22":{"type":"da","label":"","description":"End Date:","validation":{"rq":false},"choices":[],"questionKey":""},"55":{"type":"cm","label":"Practitioner","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Author of CCD","other":false},{"id":"2","label":"Custodial Organization","other":false},{"id":"3","label":"Facility Data","other":false},{"id":"4","label":"Practitioner ID Information","other":false},{"id":"5","label":"Primary Care Practitioner","other":false},{"id":"6","label":"Visited Clinic Data","other":false}],"questionKey":""},"50":{"type":"tl","label":"Type name below as signature","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"37":{"type":"ts","label":"City:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"68":{"type":"cm","label":"15) Requestor is also required to complete a List of Authorized Data Users and submit a Confidentiality Agreement signed by each user. OneHealthPort will provide these documents to the data requestor and collect all signed documents.","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"I agree to provide a Confidentiality Agreement executed by each authorized data user prior to accessing the CDR data.","other":false}],"questionKey":""},"24":{"type":"cm","label":"11) Will the data be linked with existing organizational patient data, such as with EHR data?","description":"","validation":{"rq":true},"choices":[{"id":"1","label":"Yes (describe below)","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"16":{"type":"cm","label":"7) Select the type of data product you are requesting (check only one option):","description":"","validation":{"rq":true,"mns":0,"mxs":1},"choices":[{"id":"1","label":"Custom Data Extract ","other":false},{"id":"2","label":"Custom Analytic Report","other":false}],"questionKey":""},"6":{"type":"tl","label":"Address 1:","description":"","validation":{"rq":true},"jiraField":"customfield_12083","questionKey":""},"39":{"type":"ts","label":"State:","description":"","validation":{"rq":true},"choices":[],"questionKey":""},"17":{"type":"cm","label":"8) Do you have a list of patients for whom you are requesting data?","description":"","validation":{"rq":true,"mxs":1},"choices":[{"id":"1","label":"Yes","other":false},{"id":"2","label":"No","other":false}],"questionKey":""},"25":{"type":"rt","label":"Describe what data will be linked to the CDR information:","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"64":{"type":"cm","label":"5) Are you requesting identified or deidentified data:","description":"","validation":{"rq":true,"mns":0,"mxs":1},"choices":[{"id":"1","label":"Identified","other":false},{"id":"2","label":"Deidentified","other":false}],"questionKey":""},"53":{"type":"cm","label":"Insurance","description":"","validation":{"rq":false},"choices":[{"id":"1","label":"Insurance Contact Info","other":false},{"id":"2","label":"Patient's Insurance","other":false}],"questionKey":""},"2":{"type":"tl","label":"Requestor Name:","description":"","validation":{"rq":true},"jiraField":"customfield_12048","questionKey":""},"38":{"type":"tl","label":"Address 2:","description":"","validation":{"rq":false},"choices":[],"questionKey":""},"29":{"type":"cm","label":"14) Do you plan to share the CDR data or derived data products with anyone other than the authorized data users from your organization?","description":"","validation":{"rq":true},"choices":[{"id":"3","label":"Yes (OneHealthPort will provide a Recipient Data Output that is required for the application)","other":false},{"id":"4","label":"No","other":false}],"questionKey":""},"41":{"type":"tl","label":"Requestor Title:","description":"","validation":{"rq":true},"choices":[],"questionKey":""}}},"uuid":"1a4bbba8-d706-4dd5-8fb3-34f9d4dc8527"},"linkedJiraFields":["customfield_12083","customfield_12030","customfield_12048"]},"key":""},"portalWebFragments":{"headerPanels":[],"subheaderPanels":[],"footerPanels":[],"pagePanels":{"propertyPanels":[],"legacyPropertyPanels":[]}}}