MSQC Data and Report Request Form

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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: MSQCCustomerSupport@med.umich.edu

Email *

Please acknowledge/confirm the following:

1) I have read and understand the terms of the MSQC Data Request Policy: https://drive.google.com/file/d/1Jprpwo9r-rsUVZyWmkKd6RYdwaRv95eH/view?usp=sharing

2) I will NOT SHARE this data with any other individuals other than those indicated on this Data Request Form.

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

4) 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 *

Full Name *

Phone Number *

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

Start Date *

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

YYYY

End Date *

Please select the end date of the time period FOR THE DATA 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

Do you require statistical support from MSQC statisticians? *

Please note, due to the limited bandwidth of MSQC staff, requests for statistical support may result in increased lead time for data requests. If MSQC statistical support is utilized for analysis and the project results in a publication, we do expect MSQC to be stated as the data source and the MSQC-provided statistician to receive authorship.

Yes

Maybe

Is there a timeline you are expecting to meet? *

MSQC is first and foremost a Quality Improvement group. While we cannot guarantee meeting research timelines due to other priorities, this helps us be transparent about expectations from both parties.

If requesting a dataset, who will be accessing this dataset? Please state their full names and emails. If not applicable, please write N/A. *

Reminder that you are not permitted to share provided datasets with anyone other than those indicated on this form.

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