Connection Request Date/Time
Now M-D-Y H:M
What is your role in this study?
* must provide value
Principal Investigator
Study Coordinator/Other
Requestor JHEDID
* must provide value
Principal investigator JHEDID
* must provide value
First Name *must provide value Last Name *must provide value
Email Address *must provide value
Affiliation *must provide value How Did You Hear About Connection Request? *must provide value
First Name
* must provide value
Last Name
* must provide value
Department
* must provide value
Phone (pulled form API)
* must provide value
Requestor Title (pulled form API)
* must provide value
Requestor Affiliation (pulled from API)
* must provide value
Requestor Original DN (pulled from API)
* must provide value
Email Address
* must provide value
Affiliation(s)
* must provide value
Requestor Affiliation Other
First Name *must provide value Last Name *must provide value
Email Address *must provide value
Affiliation *must provide value
Principal Investigator First Name
* must provide value
Principal Investigator Last Name
* must provide value
Principal Investigator Department
* must provide value
Principal Investigator Affiliation (pulled from API)
* must provide value
Principal Investigator Original DN (pulled from API)
* must provide value
Principal Investigator Phone (pulled from API)
* must provide value
Principal Investigator Title (pulled from API)
* must provide value
Principal Investigator Email
* must provide value
Affiliation(s)
* must provide value
How did you hear about the ICTR Connection Request?
Project Title *must provide value
Do you have IRB approval? *must provide value IRB Number
Stage of research *must provide value
Describe the aims of the project (1-2 sentences): *must provide value
Project Title
* must provide value
Do you have IRB approval?
* must provide value
Yes No Pending Exempt
Stage of Research:
* must provide value
This project is supported by:
* must provide value
Describe the aims of the project (1-2 sentences):
What type(s) of support are you interested in:
An existing project
A future project
Non-project specific consult
Other
Begin an ICTR Service Request Select the service or services you would like to use. If you need more information about a particular program, just hover over the "Details" next to the program name.
We'll ask you some questions, give you the opportunity to upload some supporting documents, and then pass your request on to our experts. You'll receive an email acknowledgement of your submission right away.
General Help: Ask a Research Navigator
Analysis/Biostatistics Community Engagement/Recruitment Clinical Research Data/Informatics
Study Planning/Study Conduct Drug and Device Development Regulatory Support ICTR Communications
Community Engagement/Recruitment
Clinical Research Data/Informatics
CCDA Sub Items
* must provide value
Agreement to not attempt to re-identify any data in this training dataset. I agree to:
• Not re-distribute this data in any form
• Use this data only on the secure PMAP data platform
• Recognize that while this data is de-identified, it is patient data and should be managed and protected respectfully
* must provide value
Drug and Device Development
Please enter your general question for the ICTR Navigator.
I have no knowledge of REDCap and would like more information
I know what REDCap is, but I do not know where to start
I need to contact a REDCap administrator about my project
Selected services: "_____ denotes none selected for that group" General Help ______
______
Analysis/Biostatistics: ______
Community Engagement/Recruitment: ______
Clinical Research Data/Informatics: ______
______
Study Conduct: ______
Drug and Device Development: ______
Regulatory Support: ______
ICTR Communications ______
Please select at least one choice from any of the services above before clicking "Submit" The choice(s) you have made require additional forms to be completed. Click Submit (below) to continue to each additionally required questionnaire. ______
Additional Required Surveys
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