AIMS DATA REQUEST FORM
Most reports require at least one week or more lead time from the date the request was sumitted.
First Name
*
Last Name
*
Email
*
Department
*
Anesthesiology Admin
Billing Hospital
CQI
HMC
Hospital Admin
Research
Surgery
Nursing
UWP
Other
Phone Number
*
xxx-xxx-xxxx
General Report Description
Request Type
*
Billing/Compliance
Quality Assurance
Administrative
Educations
Research
Other
If Research is selected please enter IRB# Below
Research IRB#
Report Name
*
Purpose of the report
*
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