First Name
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Last Name
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E-mail Address
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Are you an employee of a GPC institution?
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Yes
No
Institution
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Allina Health Indiana University Intermountain Healthcare Marshfield Clinic Research Foundation Medical College of Wisconsin University of Iowa University of Kansas Medical Center University of Missouri University of Nebraska Medical Center University of Texas Health Science Center San Antonio University of Texas Southwestern Medical Center University of Utah
Name of institution you are affiliated with
You are a:
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Health System Representative
Investigator/Researcher
Patient
Reason for Request (check all that apply)
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Development and validation of computable phenotypes
Identification of study subjects
Identification and engagement of CDRN affiliated clinics or hospitals for research
Observational research with subject recruitment and data collection
Obtaining counts for feasibility or sample size estimates
Pragmatic clinical research
Research on de-identified or limited data (without subject contact)
Stakeholder engagement to guide research efforts
Survey research
Other
Do you have faculty status at a GPC institution or have you identified a GPC faculty collaborator, and do you have funding support identified for your project?
If yes, and you only need feasibility counts, de-identified or limited data - stop here, and proceed directly to the GPC Query and Data Request Form
If no, or if you need additional services, please complete this Research Opportunity Assessment before requesting feasibility counts or data.
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Yes
No
Other: Please explain the reason for the request.
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Please describe your current methods of stakeholder engagement in this project.
If you plan to recruit patients to participate in your study, please describe the perceived benefits and risks for patients to participate.
If you plan to recruit providers, clinics, or hospitals to participate in your study, please describe the perceived benefits and risks for participation.
Please briefly describe your study and collaboration goals.
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Do you have an executable/electronic phenotype algorithm already in place to identify subjects?
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Yes
No
Not Applicable
If you need to identify patients electronically, please include a complete phenotype algorithm if available.
Do you have a GPC PI Collaborator?
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Yes
No
I am the GPC PI
Name of the GPC PI Collaborator
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First Last
Please indicate the area of expertise you are seeking for your GPC PI Collaborator.
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If you are external to GPC, please describe the benefits for the GPC PI for participation.
Please indicate the GPC sites you wish to collaborate with (check all that apply)
Allina Health
Indiana University
Intermountain Healthcare
Marshfield Clinic Research Foundation
Medical College of Wisconsin
University of Iowa
University of Kansas Medical Center
University of Missouri
University of Nebraska Medical Center
University of Texas Health Science Center San Antonio
University of Texas Southwestern Medical Center
University of Utah
What type of expertise are you requesting for this project (check all that apply)?
Bioinformatics
Community Engagement
Content Expertise
Epidemiology
Ethics
Expertise in Comparative Effectiveness Research
Expertise in Pragmatic Clinical Trials
Physician/Practice Engagement
Process/Methods Expertise
Recruitment
REDCap for Data Management
REDCap for Electronic Consent and/or Survey
Study Design Support
None
Other
In what area do you need content expertise?
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Please explain the type of expertise you are requesting.
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List the experts you have identified and would like to participate in your project:
Do you have IRB approval?
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Yes
No
Please provide IRB approval number.
Please upload your IRB protocol, if available.
Please explain your plan for obtaining IRB approval.
Does your project already have funding?
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Yes
No
How do you intend to obtain funding or otherwise pay for your project? Please describe your funding situation:
Please provide a link to the grant you are receiving or have applied for.
Please upload your budget, if available.
Please acknowledge that you are aware that the costs of the project/study will be supported by your program budget.
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I am aware that the cost of the project/study will be supported by my program budget.
Please describe your engagement efforts to date and/or what you plan to do to involve patients, consumers and other stakeholders in your study.
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Please provide links to any relevant websites or other information about your study.
Please upload a Letter of Support template, if available.
Please upload your Letter of Intent template, if available.
Please upload your biosketch, if available.
Please provide any information about your study which you would like to make publicly available on the Greater Plains Collaborative website. Commonly included information includes a short description, the Principal Investigator, the date the application is due, the status, the expected start of the trial, and links to any websites with more detailed information.