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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

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FWQoemhsPDf9GsVYr3sXc6HLJhbMhFqS9iFpTcpuUcWkaj5wousEGLQG37g9bcCqkHXDJLfItmgaCjWC5uaTW

GPC Research Opportunity Assessment

Please complete this Research Opportunity Assessment survey if you are interested in collaborating with the GPC.

Thank you for your interest - we look forward to working with you!

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

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Institution

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Name of institution you are affiliated with

Role at your institution

You are a:

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Health System Representative

Investigator/Researcher

Patient

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Tell us about yourself:

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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

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Other: Please explain the reason for the request.

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Please describe your current methods of stakeholder engagement in this project.

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If you plan to recruit patients to participate in your study, please describe the perceived benefits and risks for patients to participate.

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If you plan to recruit providers, clinics, or hospitals to participate in your study, please describe the perceived benefits and risks for participation.

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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

Not Applicable

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If you need to identify patients electronically, please include a complete phenotype algorithm if available.

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Do you have a GPC PI Collaborator?

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Yes

I am the GPC PI

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Name of the GPC PI Collaborator

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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.

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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:

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Do you have IRB approval?

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Yes

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Please provide IRB approval number.

Please upload your IRB protocol, if available.

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Please explain your plan for obtaining IRB approval.

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Does your project already have funding?

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Yes

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How do you intend to obtain funding or otherwise pay for your project? Please describe your funding situation:

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Please provide a link to the grant you are receiving or have applied for.

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Please upload your budget, if available.

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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.

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Please upload a Letter of Support template, if available.

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Please upload your Letter of Intent template, if available.

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Please upload your biosketch, if available.

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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.

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