ࡱ> c bjbjZWZW 8=`\8=`\  `````ttt8dtvL"""qvsvsvsvsvsvsv$x{~v`"!""""v``v*$*$*$"F``qv*$"qv*$*$Jlkyq)o`"FoB]vv0v'p|"|qq|`1q,""*$"""""vv*$"""v""""|""""""""" > &:  RELEASE TO INSPECTOR REQUEST FORM (Research) This form is to be used for an external collaborating researchers, monitor or auditor to access the Electronic Medical Record (EMR) for research purposes. Please ensure you have read the following procedures:  HYPERLINK "http://www.rch.org.au/policy/policies/EMR_Access_for_External_Collaborating_Researchers,_Monitors_and_Auditors/" Access of the Electronic Medical Record (EMR) system by External Collaborating Researchers, Monitors and Auditors (ECRMA)  HYPERLINK "http://www.rch.org.au/policy/policies/epic-appropriate-use-for-research/" EPIC: Appropriate Use for Research Note: for each request a static PDF file will be created for the requested patients and a login provided which is valid for up to 37 days, as such separate requests must be completed for each monitoring visit.Study DetailsRCH HREC Reference: Project title:Principal Investigator:Requestor:Request Type FORMCHECKBOX  Initial request (first request for this study)  FORMCHECKBOX  Repeat request (for this study)Monitor DetailsMonitor name(s) Note: multiple monitors may be listedAccess start date (first date of monitoring visit)Access End date  Note: must be within 37 days of start dateNumber of uses (maximum 99)Participant details (copy rows as needed)Name (first and last)UR numberConsent form FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMR FORMCHECKBOX  Attached (copy)  FORMCHECKBOX  Scanned in EMRComments:  SignatureDatePlease submit an electronic copy signed by, or emailed from the PI to  HYPERLINK "mailto:HIS.ReleaseToInspector@rch.org.au" HIS.ReleaseToInspector@rch.org.au (Health Information Services)     Release to Inspector Research Request (v2 - updated Dec 2017) Page  PAGE 2 of  PAGE \* MERGEFORMAT 2 RDE November 2012 Page  PAGE 1 of  PAGE \* MERGEFORMAT 1 #./01  U V W Y y z  L ̻ڪ}sk^sTO hm5h h *0J5jh 5Uh^h^5h h^0J5jh 5U h 5jh 5U h *5 h^5 hBhld hBh5B*CJ$aJ$ph hBhld5B*CJ$aJ$phh^5B*CJ$aJ$phhld5B*CJ$aJ$ph.jhj-5B*CJ$UaJ$mHnHphu/01 cSS? 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