Unified Clinics Research Application

Project Title:*

Principal Investigator (PI):*

First NameLast Name

PI Email:*

WMU Affiliation:*

Co-PI(s): Please provide the name and email of other researchers.

Study Start Date:*

Date

Study End Date (if known):

Date

FUNDING

Funding Source and Program Title (if applicable):

Funding amount (if applicable):

Funding Duration in months (if applicable):

INSTITUTIONAL REVIEW BOARD (IRB) APPROVAL

Does the project require IRB approval?*

YESNO

If YES, HSIRB Number

If YES, HSIRB Approval Date:

MonthDayYear

If YES, please upload a copy of your HSIRB Proposal & Approval Letter:

pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

Please provide a brief description of the project, including its objectives, purpose, and methodology (maximum of 600 words).

Has your project been piloted elsewhere? If yes, please describe:

CLINICAL TRIAL

If the study is registered at clinicaltrials.gov, please provide the registration number.

STUDY LOCATION

Please list the physical locations where data collection or study activities will take place. For activities and data collection at the Unified Clinics, describe which space you are requesting, how it will be used, and frequency.*

STUDY POPULATION

Please describe the target population or participant group for the study and how participants will be involved.*

MEDICAL RECORDS

All participant’s activities at the Unified Clinics (UC) should be registered and checked in to the UC medical records system, the Point-n-Click (PnC).

Will you need access to PnC?*

YESNO

if YES, What will you need access to within PnC (i.e.,templates, schedule, patient chart, etc.)?

DATA STORAGE

How data will be stored?*

Are data privacy measures in place (e.g., HIPAA compliance)?*

PLEASE REVIEW THE CHECKBOXES BELOW:

I will promptly inform the UC and RCFC directors of any alterations to the project concerning the target population, methodological approach, or the utilization of physical space and materials/equipment.

I will promptly inform the UC and RCFC directors of any modifications to the IRB documentation.

All participants must check in at the front desk upon arrival.

All individuals involved in data collection at the Unified Clinics must complete the UC onboarding process before commencing data collection.

ADMINISTRATIVE SUPPORT:

Please describe the administrative support you are requesting (i.e., scheduling, registering in PNC, and checking in research participants).*

SUPPLY COSTS (see fee schdule below):

Please describe how you will cover space, personnel, and supply costs incurred by Unified Clinics.*

FEE SCHEDULE:

SUSTAINABILITY OF PROJECT:

If this is a clinical service, please describe how you will sustain this service beyond the research project.*

Thank you.

We will review your application and get back to you shortly.

The Unified Clinics

Research Application at Unified Clinics