Submit AI Tool for Review

By completing and submitting this form, you are confirming that you have reviewed the Department of Health and Human Services Playbook for Trustworthy AI and your proposed AI/ML tool is intended to be used within UCSF Health.

Primary Contact Email

Enter email of person that should be contacted in response to this request.

Primary Contact

Name and role of primary contact for this AI/ML model

AI/ML Model Name

Please enter the name of your AI/ML tool

Vendor/Creator

Please enter the name of the firm or the UCSF researcher responsible for creating the tool.

Target condition predicted by AI/ML

Please describe what problem this tool is designed to address.

What is the form of the AI/ML model?

i.e. linear regression model or neural network; stand-alone or embedded in another tool?

Who are the target users of the outputs of the AI/ML model?

i.e. inpatient providers using APeX, radiologists interpreting CT scans, oncology RNs in infusion center, etc.

What is the target population of the AI/ML model?

i.e. adult patients with Acute Kidney Injury admitted to UCSF