Public Health Informatics Training Materials Request

By completing this form, you are requesting access to the Regenstrief Institute Public Health Informatics Training materials. These include several datasets consisting of real EHR and public health data with prepared training exercises. These materials are only to be used for educational purposes and cannot be used for research.By completing this form, you agree to allow us to contact you to obtain feedback on the usefulness and effectiveness of the training materials.

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* 1. Please provide your name:

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* 2. Please provide your email address:

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* 3. Please provide your telephone number:

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* 4. Please provide the formal name of your institution. EX: The Trustees of Indiana University.

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* 5. Please provide the program name that you are considering using these materials for. EX: T15 informatics training program". 
(If there is no specific program, please enter your department.)

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* 6. Please provide the name of the course you are considering using these materials in. Enter 'N/A' if you have no plans yet to use these materials.

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* 7. Which materials would you like to use in your training program or course? Please select all that apply.

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* 8. Please provide the first and last name of your institutional signature authority. This is the individual who will sign on behalf of the educational program and has the authority to sign data agreements at your institution.
(Leave blank if unknown.)

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* 9. Please provide the email address of your institutional signature authority. 
(Leave blank if unknown.)

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* 10. Please provide the first and last name of your institution's HIPAA privacy or security officer. 
(Leave blank if unknown.)

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* 11. Please provide the email address of your institution's HIPAA privacy or security officer.
(Leave blank if unknown.)

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* 12. Thank you for taking the time to complete our survey. We looking forward to working with you. We will follow up with you in the next 3-4 business days. Please feel free to provide us with any other comments or information you feel may be relevant to this request. 

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