PowerChart Report Request

Please complete the form below

Requestor

Name of the person requesting the report

First Name

Last Name

contact email for the person requesting the report

Person filling out this form, if different from above

First Name

Last Name

Email of person filing out request, if different from above

Phone number for requestor

(###)

###

####

Department

Supervisor

Reason for request

Type of Report

One Time report

Report that will need to be run regularly or on an as needed basis

Report Description

Please describe the report in detail. Specific date ranges or drug names or diagnosis codes or lab values should all be spelled out. The more specific you can be, the more quickly we can build your report. Also, please specify exactly what the output of your report should display? Name? age? drug name? dates?

Will the report be used for research purposes (as opposed to administrative or clinical purposes)?

If report is for research please include the IRB number in report description

yes

Date

When is this report needed (we cannot guarantee this date, but please give us an estimate)?

YYYY

Who will need access to this report?

Comments / clarification?

Is there anything else we need to know to help us create this report?