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
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: c5ee0b19719 (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
Mentor Information
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

Description of Topic

(limit: 1000 characters)
(limit: 500 characters)
(limit: 500 characters)
(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.

(limit: 500 characters)

(limit: 500 characters)

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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