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Proposal Registration and Consultation Request Form

Investigators and research teams engaging in clinical and translational science across our Academic Health Center who would like to benefit from CCTST services and resources should register projects and proposals. Please complete the form below and submit it for processing. Our Research Central staff will review it and respond within 3 business days. Guidelines on accessing support through Research Central are here.

Researcher Information

Researcher's
First Name:

Researcher's
Last Name:

Form Submitter (if different than researcher):

First Name:

Submitter Last Name:

Submitter Email:

Researcher's

Department:

Division:

Researcher's
Primary Institution:

UC CCHMC Cincinnati VAMC
Other: please specify:

Researcher's
Contact Info:

Office Phone:

Cell Phone:

Pager:

E-mail:

Researcher's
Terminal degree(s)
(Check all that apply)

MD DDS PhD PharmD
RN MPH MS or MSc

Researcher's
Academic rank

Professor
Associate Professor
Assistant Professor
Instructor

Trainee (please specify):
      Fellow
      Resident
      Medical student
      Graduate student
      Undergraduate student

If applicable, provide details of mentor (required for trainees and Instructor-level researchers, recommended for assistant professors):

Mentor's Name:

Mentor's Department:

Mentor's Division:

Project Information

Project Title:
Project Description:
Upload Proposal File (optional):

Type of Study (check all that apply)

Patient-oriented research

Clinical trial

Pharmacologic study

Genetic/genomic study

Educational or behavioral study

Meta-analysis/systematic review

Primary data collection outcomes study
(e.g., epidemiologic or quality of life study)

Health policy research
(e.g., decision analysis/cost-effectiveness analysis)

     Large database analysis
          (e.g., Medicare, Behavioral Risk Factor
          Surveillance System)

Career development award

Other (describe):

Is this a multi-site study? Yes No

Funding source (check all that apply)

NIH or other USPHS

Cincinnati Children's Research Foundation

UC internal grant

Industry

Divisional or Departmental funds

Foundation (specify):

Other (describe):

Unfunded

Data sources (check all that apply):

Status of the data collection (select one):

New (prospective) data collection

Planning phase or new

Existing data set

Ongoing

Electronic medical record

Completed dataset

Laboratory or medical test data

Standardized questionnaires

Support requested

What type of support do you need? (check all that apply)
Study design consultation		Data management support
Help with response to review of grant or manuscript			Database design and creation
Questionnaire development:			Data capture (please specify)
Will questionnaires be completed by:				Paper-based record forms - direct
	patients/parents			data entry, teleform
	local study staff			Electronic data collection
	remote site study staff	Data analysis
	not yet determined	Statistical plan or sample size for planned study
	not sure	Regulatory/Ethical issues including IDEs/INDs
Other Informatics support (i.e. use of EMR data collection, data warehouse queries/access, etc.)		Budgeting
Other (describe):
Not sure what support I need
If you have already discussed this project with a methodologist, biostatistician, data analyst or data manager, please include their name(s):

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NIH Acknowledgement: Publications resulting from the use of CCTST resources must credit the appropriate CCTST grant by including an NIH Funding acknowledgment.