GPC Research Opportunity Assessment

First Name

Last Name

E-mail Address

Are you an employee of a GPC institution?

Institution

Name of institution you are affiliated with

Role at your institution

You are a:

Tell us about yourself:

Reason for Request (check all that apply)

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.

Other: Please explain the reason for the request.

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.

Do you have an executable/electronic phenotype algorithm already in place to identify subjects?

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

Do you have a GPC PI Collaborator?

Name of the GPC PI Collaborator

Please indicate the area of expertise you are seeking for your GPC PI Collaborator.

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)

What type of expertise are you requesting for this project (check all that apply)?

In what area do you need content expertise?

Please explain the type of expertise you are requesting.

List the experts you have identified and would like to participate in your project:

Do you have IRB approval?

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?

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.

Please describe your engagement efforts to date and/or what you plan to do to involve patients, consumers and other stakeholders in your study.

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.