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Data and AI Governance Initial Request Form

Please complete the initial request form below. This information will help us triage your request to the appropriate governance review processes. If you have questions, please contact Data Governance Team (governance.dataandai@pennmedicine.upenn.edu)

Thank you!

Name of the person who is the sponsor/champion, business owner, transaction manager, and contract negotiator, PI, etc.; someone who is responsible for leading and moving the project forward.

Penn Medicine email address of this leader.

Phone number (Please provide the best number to reach the leader.)

Are you the leader (sponsor/champion, business owner, transaction manager, and contract negotiator, PI, etc.; someone who is responsible for leading and moving the project forward), or are you a delegate submitting the project on behalf of the leader?

Leader

Delegate

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Should a delegate contact information be included in this request?

Yes

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Delegate Name

Delegate email address.

Delegate phone number.

Please provide the primary email address for sending governance feedback, questions and additional forms that may need to be completed.

* must provide value

Affiliation

PSOM Department

PSOM Center

UPHS Entity

UPHS Corporate Department

Other

Please specify the PSOM Department

Please specify the PSOM Center

Please specify the UPHS Entity

Please specify the UPHS Corporate Department

Please specify all other entities.

Please specify the urgency of your request.

Low: 15+ business days turnaround needed

Medium: 10-15 business days turnaround needed

High: 1-5 business days turnaround needed

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Request Title: Please provide a short title for your request (2-5 words; e.g. "Yoga SaaS Implementation").

Please provide a brief description of the request/initiative/project. What problem are you trying to solve? Who are the data recipients, if relevant? What products or services are to be used or developed?

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IRB protocol number (if applicable)

Please check the type of governance request.

AI (Artificial Intelligence)

Data access

Data standards

Data platforms/cloud

Data quality

Other

Please describe the other type of governance request.

Please check any of the following requests that will be a part of the project.

Access to internal data

Ingesting external data

Sharing data externally

Data Deletion/ Retention / Archival

New Data Standards / Policy

Data analytics

New Data Related Technology

Public or synthetic data

Other

Please describe the other request(s) that will be a part of the project.

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What are the benefits of this request? (i.e compliance requirements, financial, new opportunities, process improvement, efficiency improvement, new research).

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Please check any potential risks as a part of the project.

Limited resources

Vendor(s)

Privacy

Data security

Appropriate agreements in place

Foreign interest

Compliance

Other

Please describe the other risk that was identified.

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How is this project financially sponsored?

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Do any regulation compliances apply?

HIPAA/PHI

PII

None

Other

Describe any known compliance obligations associated with this project.

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Please select from the following descriptive categories that indicate the general purpose of your project / request.

Treatment / clinical

Quality improvement (QI)

Research

Payment or operations

Marketing

Patient communication

Public health

Education

Required by law or contract

Other

Please describe the other general purpose of your project / request.

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Since you have indicated that the purpose is either quality improvement (QI) or research, which of the following apply?

The project / request is QI and is not going to be submitted to the IRB.

The project / request is QI and is going to be submitted or has been submitted and is awaiting a formal determination.

The project / request is QI and the IRB has made a formal determination.

The project / request is research and is going to be submitted or has been submitted to the IRB and is awaiting approval.

The project is research and has been approved by the IRB.

The project has no human research involved, no IRB to be submitted

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Since you have indicated that the project / request has been approved, please provide the IRB number.

Please upload a copy of your most recent IRB protocol.

Upload file

Will data be used as a part of this project?

Yes

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What data are being used?

Production

Development

Proof of concept/sample of data set

Please select the data delivery mechanisms that apply to this project.

Data will not be moved - query in place

Data will be moved externally

Data will be moved internally

Describe generally, what data are involved?

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What type of data will be included in your request?

Claims

Billing

Provider

Patient

Employee

Operations/business

Other

Are the data:

Identifiable

Deidentified

Limited dataset

Recurrence of Request: Please select one of the following in terms of the expected one time or recurring governance review.

One time

Recurring

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Please provide the expected or targeted start date.

M-D-Y

Additional Documentation Upload File 1: Please upload any relevant documents. Helpful information may include additional descriptions, business case documents, data flow diagrams, etc. We will inquire further if more detail is needed.

Upload file

Additional Documentation Upload File 2: Please upload any relevant documents. Helpful information may include additional descriptions, business case documents, data flow diagrams, etc. We will inquire further if more detail is needed.

Upload file

Additional Documentation Upload File 3: Please upload any relevant documents. Helpful information may include additional descriptions, business case documents, data flow diagrams, etc. We will inquire further if more detail is needed.

Upload file

Please enter today's date by clicking on the "Today" button before submitting.

M-D-Y

Triage Review Status (archive this status as of 10/2/24)

New

Under Review

Needs Additional Information

Completed: Approved

Withdrawn

Denied

Escalated

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Triage Review Comments

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Triage Reviewer(s)

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Additional Documentation Upload File 4: Please upload any relevant documents. Helpful information may include additional descriptions, business case documents, data flow diagrams, etc. This is in addition to what they requestor may have submitted.

Upload file

Additional Documentation Upload File 5: Please upload any relevant documents. Helpful information may include additional descriptions, business case documents, data flow diagrams, etc. This is in addition to what they requestor may have submitted.

Upload file

Additional Documentation Upload File 6: Please upload any relevant documents. Helpful information may include additional descriptions, business case documents, data flow diagrams, etc. This is in addition to what they requestor may have submitted.

Upload file

Route Specific Governance Forms

Data access

Data standards

Data platforms/cloud

Send Governance Forms

True

False

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Send for co-lead review.

Yes

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Which governance co-leads should review?

Data access

Data standards

Data platforms/cloud

Security

Email address for Danielle Mowery, AI Governance Co-Lead 1

Defaults to "dlmowery@pennmedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Mike Horst, AI Governance Co-Lead 2

Defaults to "michael.horst@pennmedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Kristen Dubesky, Data Access Governance Co-Lead 1

Defaults to "kristen.dubesky@pennmedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Maya Nayak, Data Access Governance Co-Lead 2

Defaults to "nayak1@upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for John Salmon, Data Standards Governance Co-Lead 1

Defaults to "john.salmon@pennmedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Angie Gambler, Data Standards Governance Co-Lead 2

Defaults to "angela.gambler@pennmedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Mike Zinni, Data Platforms Governance Co-Lead 1

Defaults to "michael.zinni@pennmedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Laura Fluharty, Data Platforms Governance Co-Lead 2

Defaults to "lauraee@upenn.edu"
Hidden on surveys and PDFs
Needed for AI governance co-lead review

Email address for Mike Moran, Security

Governance Co-Lead 1

Defaults to "Michael.Moran@PennMedicine.upenn.edu"
Hidden on surveys and PDFs
Needed for Security co-lead review

Email address for Robert Spratt, Security

Governance Co-Lead 2

Defaults to "Robert.Spratt@Pennmedicine.upenn.edu.edu"
Hidden on surveys and PDFs
Needed for Security co-lead review

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