大象传媒
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Department of Medicine
Division of General Medicine and Clinical Epidemiology
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Research Committee and Project Application
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Research Project Application
Research Project Application
This form is used to apply for permission to conduct research within our clinic.
Step
1
of
3
33%
Project Information
Name of Project
(Required)
Principal Investigator
(Required)
Contact Email
(Required)
Division Sponsor
(Required)
(if you're a PI within the Division select yourself)
ALEMAN
BERKOWITZ
CAREY
CAVANAUGH
CHELMINSKI
CHUNG
COLFORD
CYKERT
DEWALT
DOLAN-SOTO
EL AMRAOUI
FELTNER
GREIG
IVES
JONAS
KEYSERLING
KLIPSTEIN
MALONE
MILLER
PALMER
RATNER
REULAND
SCOTT
SHAHEEN
SHILLIDAY
SMITHSON
WEIL
WILEY CENE
OTHER
If "Other," Who?
(Required)
Research Question
(Required)
Brief Description of the purpose of the research
(Required)
Estimated Start Date
(Required)
MM slash DD slash YYYY
Estimated End Date
(Required)
(use 1 year from start date if unsure)
MM slash DD slash YYYY
Type of Project
(Required)
Rsearch
CQI
Funded?
Yes
No
If Yes, Type of funding
(Required)
NIH
AHRQ
Foundation
大象传媒 internal funding
Other
If No, what will data be used for?
(Required)
CQI data
Pilot data for future funding
Other
Stage
NIH
Foundation
Graduate Work
CQI Study
Other
Study Population
Age Range Start
(Required)
Age Range End
Races
(Required)
All Races
Caucasian
African-American
Asian
American Indian
Other
Gender
(Required)
Male
Female
Both
Number of Participants
(Required)
Disease State
Anticoagulation
COPD/Asthma
Diabetes
Heart Disease
Heart Failure
Hypertension
Oncology
Pain
Psych
Renal Disease
Screening and Prevention
Other
Recruitment Information
Recruitment Location
(Required)
Registry
In Clinic
Phone
Other
Recruitment Method
(Required)
Will you require an RA to be in the Clinic?
(Required)
Yes
No
If Yes, How Many 1/2 Days per Week Will They Be There?
(Required)
What Space Will They Need at Eastowne?
(Required)
Not Applicable
Exam Room
Cubicle/Desk
Hallways
Waiting Room
Other
Other
(any special considerations or special needs)
Upload a copy of your IRB Application
(Required)
(scanned version of your approved IRB, stamped document is preferred)
Max. file size: 98 MB.
Upload a copy of your approval letter
(scanned version of your approval letter)
Max. file size: 98 MB.
Comments
This field is for validation purposes and should be left unchanged.
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