Information Technology
Research Request for Exception from UCDHS Technology Evaluation
Version 2.0
Clinical Research Study: Click here to enter Study Name
Principal Investigator: Click here to enter PI.
Email: Contact Email
Date: Enter a date.
PI Contact/Requestor: Requestor name
Phone: Contact Phone
Study Duration: Duration
Definitions: For the purpose of this document the term “Study” refers to clinical trials, clinical studies or other research
related activities. The term “Technology” refers to any computing system, device or application that process or stores
information (e.g. computer applications, computers, servers, mobile devices and clinical devices), that is provided by the
Study sponsor for use in the Study.
Study Description:
Click here to enter the Study Description. Please include 1) General description of the study, the number of expected
patients, approximate number of staff using the technology, the study duration; 2) How will the Technology be used, i.e.
what will be accomplished with the Technology.
General Technology
Yes/No
1. Does the Study require the use of data center servers to be located at UCDHS? (either existing or a new
server implementation)
Yes/No
2. Does the Study require a Technology dependency with any UCDHS production information system (e.g.,
Epic, Clarity, labs, radiology, pharmacy, etc.)?
Security
Yes/No
3. Is unencrypted PII/PHI stored or processed on/by the propose Technology or elsewhere?
Hospital Policy & Procedures Policy 1313: Protected Health Information (PHI) or Personal Information (PI)
on Mobile Devices and Personal Computers (PCs)
Note: if yes please describe (within the Study Description above) the encryption algorithm and bit strength
to be used.
Yes/No
4. Is PII/PHI stored/transmitted to an outside party (outside of UCDHS)?
Yes/No
5. Is there a requirement for removable media (e.g., flash/thumb drives, CD/DVDs, external hard drives,
etc.) between UCDHS laptops/desktops and the proposed Technology?
Networking
Yes/No
6. Will the Technology need to connect to any UCDHS wired or wireless networks?
(All exceptions for Guest wireless Study use will be considered on a case-by-case basis)
Yes/No
7. Will the Technology require customer or vendor provided Wi-Fi networks (“hotspot”) or other networking
requirements/equipment not provided and supported by UCDHS?
Clinical Engineering
Note: Clinical Engineering requires a separate review for clinical devices.
1