CLOSED CLAIMS PORTAL
ASA Closed Claims Data Request
The Anesthesia Closed Claims Program offers customized data retrieval as a service to members of the ASA and those mentored by ASA members. Data requests will not be granted to the general public, for commercial use or for use in litigation. Data for research will be not be granted at this time” Please check the Closed Claims webpage for future release date. For additional guidelines related to Anesthesia Closed Claims Program data requests, please visit:
www.aqihq.org/ACCMain.aspx
Notes: Please complete the entire form before submitting. You may save your form without submitting so you will be able to edit the application. Please note once your application has been submitted you will not be able to make any changes.
Case Reference Code:
dd611619172
(use this reference code for further editing of your request)
Requestor and Mentor
Active or retired ASA anesthesiologist members can receive data without a mentor. Residents or other types of ASA members or non-ASA members must have an ASA member mentor to receive data.
Requestor Information
First Name
Last Name
Email
Address
Address
City
Zip
State
unknown
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone
ASA Member #
Mentor Information
First Name
Last Name
Email
Address
Address
City
Zip
State
unknown
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone
ASA Member #
I am a(n)
Anesthesiologist ASA Member (Active or Retired)
Residents, other types of ASA members, or non-ASA members
Non-ASA member with an ASA member mentor listed below
Date Needed
Please allow for 8-14 weeks for processing
Data Use Type
What is the intended use? Please check all that apply.
Research data is not available at this time
Handout
Newsletter
Conference
Grant Application
Book Chapter
Preliminary supporting data
Other
Do you intend to publicly present or publish your work?
...
Yes
No
Unsure
If So Where
Data Specifications
...
Aggregation data report and case studies
Aggregation data report and graphs
Case studies and graphs
Aggregation data reports, case studies, and graphs
Description of Topic
Hypothesis, question, or topic of interest
(limit: 1000 characters)
Inclusion Criteria
(limit: 500 characters)
Exclusion Criteria
(limit: 500 characters)
Keywords for Search
(limit: 500 characters)
Conflict of Interest Statement
AQI Closed Claims Program Data may not be used in advertising or promotion of any commercial product or service.
Both requestors and mentors must disclose potential and actual conflicts of interest by responding to the disclosure questions and providing explanations of any positive responses, regardless of dollar value or amount.
Positive responses will be reviewed by the Closed Claims Committee for possible conflicts of interest. Examples of Funding: grants, gifts, contracts, stock options
Examples of Financial Interest: consulting, employment, patent licensing arrangement, equity interest.
Do you or your mentor have any financial interest in the subject matter, materials or equipment that is the subject of the data request?
...
No
Yes, please explain
Explain any conflicts
(limit: 500 characters)
Do you, your mentor or an immediate family member have any financial interest in or funding related to the purpose of the data request?
...
No
Yes, please explain
Explain any conflicts
(limit: 500 characters)
Within the last 5 years, have you, your mentor or an immediate family member participated in the planning, conduct, or reporting of research that has been funded by or is otherwise related to the purpose of the data request, or in any competing purpose?
...
No
Yes, please explain
Explain any conflicts
(limit: 500 characters)
Statement of Compliance
By signing below, I attest that I have completely disclosed all of my intended uses for the requested data above. I understand that data provided by AQI pursuant to this data request is intended solely for my use, and disclosure to anyone besides my listed ASA member mentor is strictly prohibited unless expressly agreed to in writing by AQI. I further understand that I am responsible for obtaining IRB approval before receiving any data from AQI if required by my institution. I will agree (and my ASA member mentor will agree) to adhere to the terms of a Data Use Agreement with AQI and AQI’s Data Use Policy if my request for data is approved.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
By checking checkbox and typing my name below, I am electronically signing my application
Checkbox
First Name
Last Name
