Research Collaboration Form

Request Date *

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What is the purpose of your request to HCN?

Study Feasibility: obtain aggregate data on potential study participants with no identified information

Cohort Identification: Obtain identified data (names, contact, etc.) of potential study participants

Preparatory-to-Research

Other

If other, please specify. *

SECTION 1: PRINCIPAL INVESTIGATOR & COLLABORATOR(S) INFORMATION

Principal Investigator - Full Name (First, LAST) *

Principal Investigator - Institution *

Principal Investigator - Institution Address *

Principal Investigator - Email Address *

Principal Investigator - Phone Number *

Do you have collaborators/key staff involved in this project?

Yes No

Collaborator/Key Staff #1- Full Name (First, LAST) *

Collaborator/Key Staff #1- Institution & Address *

Collaborator/Key Staff #1- Role in Project *

Collaborator/Key Staff #1- Email Address *

Collaborator/Key Staff #1- Phone Number *

Do you have an additional collaborator/key staff involved in this project?

Yes No

Collaborator/Key Staff #2- Full Name (First, LAST) *

Collaborator/Key Staff #2- Institution & Address *

Collaborator/Key Staff #2- Role in Project *

Collaborator/Key Staff #2- Email Address *

Collaborator/Key Staff #2- Phone Number *

SECTION 2: PROJECT FUNDING

2.1 Have you already obtained funding for this Yes project?

Yes

No, but I have already applied for funding

No, but I plan to apply for funding within thenext 12 months

Not applicable

2.2 Concisely explain why you checked that funding is "not applicable". (LIMIT 100 words) *

2.3 Which type of funding organization have you applied to (or plan on applying to) in order to fund this research? Select all that apply.

Federal (NIH, NSF, DOD, PCORi, etc.)

Industry/Pharma

Foundation

Internally-funded

Other

If other, please specify the source of funding. *

2.4 What is the proposed funding agency of the project? (e.g., NCI, NIDDK, Merck, Gilead, etc.) *

2.5 Website link to funding announcement? *

2.6 Deadline for the grant submission? *

SECTION 3 - PROJECT INFORMATION

3.1 Project Title *

3.2 Anticipated start date of the project? *

3.3 Anticipated end date of the project? *

3.4 Expected date for receiving material/data from HCN? *

3.5 Type of research?

Interventional Observational

3.5.1 List the intervention(s) that will be performed during the project. *

3.5.2 Which comparisons will be made in this observational project ? *

Drug

Device

Biologics

Social/Behavioral

Other

If other, please specify the source of funding. *

Qualitative Data Collection (e.g., surveys, focus groups, etc.)

Secondary Data Analyses (e.g., retrospective EMR data analysis)

Quality Improvement Initiatives and Programs

Randomized Control Trial - patients

Randomized Control Trial - providers

Non-identifiable voice, video, or image recordings (not all recordings are non - identifiable)

Group behavior studies not involving stress and/or where subjects cannot be identified

Chart review

Database or registry

Other

If other, please specify. (LIMIT 20 words) *

English

Spanish

Creole

Other

SECTION 4: PROJECT SCOPE - STAKEHOLDER ACTIVITIES & EXPECTATIONS

SECTION 5: PROJECT POPULATION

SECTION 6: ADDITIONAL DOCUMENTAION

6.2 Which type of documentation are you providing? Check all that apply. Email all documentation as ONE PDF.

6.3 Email Documentation (in ONE SINGLE PDF).

SECTION 7: PROJECT BUDGET

SECTION 8: TERMS OF USE

The Investigator and project team agree to not use the results of exploratory queries or any data that may be supplied for any other project or research purposes other than those outlined in this document. The investigator acknowledges responsibility for ensuring appropriate use of the query results, publications, and presentations.

SUBMITTING INSTRUCTIONS

Please submit completed form and/or any questions to: research@HCNetwork.org

Thank you!