MSQC Data and Report Request Form

To help MSQC participating hospitals fulfill their mission to improve the quality of surgical care, we aim to provide adhoc reports and data sets efficiently and accurately. This form helps us streamline your request(s) for data and/or reports by collecting the necessary information for each project.

The Data and Report Request Form will take approximately 5 - 10 minutes to complete. If applicable, you will want to have available your project description/project protocol, your IRB Approval letter, and have a clear idea of the variables you will need for your investigation.

Please allow 2 - 3 weeks to receive your request, as the time necessary to complete each request varies on complexity of request and number of requests in the queue at any given time.

When you have successfully submitted this form, you will see a confirmation page and you will receive a confirmation email with a copy of your request for your records. If you have any problems or questions during this process, please contact: MSQCDataRequest@med.umich.edu

Email address *

Please acknowledge/confirm the following:

1) I have read and understand the terms of the MSQC Data Request Policy: http://msqc.org/wp-content/uploads/2019/03/200.07MSQCPSOExternalDataRequestProcess.pdf

2) MSQC will be acknowledged as a source of information in materials presented and/or published.

3) I attest that any publication(s) resulting from this data will meet the Patient Safety Organization (PSO) standards of contextual non-identification of patients, hospitals, and/or medical professionals and remain in accordance with the Patient Safety Act (42 CFT Part 3)

I have read and understand all of the above. *

Yes

Required

MSQC Hospital Name/Institution Name *

Your answer

Full Name *

Your answer

Phone Number *

Your answer

Please give a brief description of your project or research plan. *

Your answer

Start Date *

Please select the start date of the time period requested for this project.

YYYY

End Date *

Please select the end date of the time period requested for this project.

YYYY

Select the type of data being requested. *

Data Set - case level variable information, not aggregated/adjusted

Report - table, chart, or graph of data that is aggregated and/or adjusted to display a specific outcome of interest

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