Research Proposal Form

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Name* This field is required.
First Name
Last Name
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Credentials
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E-mail* This field is required.
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Phone Number* This field is required.
Area Code
Phone Number
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Affiliation or Academic Institution* This field is required.
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Are you currently a student of an academic institution?* This field is required.
YESNO
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Please tell us about your academic institution.* This field is required.
Educational Institution
Type of Degree
Current Year of Completion (i.e. PGY1, M3, etc.)
Faculty/Mentor Name
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Are you currently working with a ProMedica Physician?* This field is required.
YESNO
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Name the physician and give a brief description of your assigned project.* This field is required.
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Will the project involve a ProMedica Senior Care facility?* This field is required.
YESNO
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What type of project are you planning to conduct?* This field is required.
Research
Quality Improvement
Case Report
Not Sure
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Research/Project:* This field is required.Please give a 1-2 sentence summary of the research/project you are planning to do.
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Resources:* This field is required.Please indicate what resources you may need to complete your research project. This is not a formal request for these specific resources; instead, this will give us an idea of the needs for this project.
Protocol development/review
Statistics
Proofreading/editing (protocol/manuscript)
Regulatory assistance
Staff education
Funding/grant writing
Clinical Research Coordinator
Pharmacy
Laboratory
Nursing time
Survey or other copyrighted materials
Other
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Would you like to set up a consult with the Research Office?* This field is required.If so, the Research Office will contact you to set up an appointment.
YESNO
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Would you like to set up a consult with the Institutional Review Board (IRB) Office?* This field is required.If so, the ProMedica IRB Office will contact you to set up an appointment.
YESNO
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Please attach your protocol or protocol draft here.* This field is required.Prior to meeting with the Research Department and/or the IRB Department, we request that you have your protocol developed in order to provide you with a thorough consultation. If you don't have a protocol developed, there is a protocol template available on the myProMedica portal. To access this template, visit myProMedica > Our System > System Departments > Research > Conducting Research. If you don't have access to myProMedica, please email phsirb@promedica.org to request the protocol template.
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Cancelof
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Have you completed CITI training?* This field is required.The Collaborative Institutional Training Initiative (CITI) Program is an online research ethics training required to be completed in order to engage in research at ProMedica.
YESNO
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CITI TrainingAll investigators and key personnel who participate in the design, conduct, or reporting of human subjects research (including exempt research) must be appropriately trained in the protection of human subjects. Specific training requirements within CITI are determined based on your role in research and the type of research you are conducting. The CITI training instructions are available below.
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Projects involving ProMedica Senior CareComplete and submit the attached form
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HCR MannorCare
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