@HIDDEN
Today M-D-Y @HIDDEN
If the project is tabled or has some other major delay enter the original review date here.
Use the JHCP Review Date variable once the project has been approved and the delays have been removed.
Today D-M-Y @HIDDEN
None
RPC
RET/Email
Research Director
BMS
@HIDDEN
Yes
No
NA
@HIDDEN
Approved
Acknowledged
Pre-IRB
Under review
Lapsed
Terminated
NA
@HIDDEN
Is this project still enrolling?
Yes
No
@HIDDEN
Today M-D-Y @HIDDEN
Notes, Comments, Concerns
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Study Title:
* must provide value
Is this a resident led project?
Yes
No
Specify IRB Being Used:
* must provide value
JHU School of Medicine IRB
JH Bloomberg School of Public Health IRB
Western IRB
Central IRB (Non-Hopkins IRB)
Non-Central (Non-Hopkins IRB)
N/A
Calc of IRB field
(hidden from survey, used for "default" on second survey)
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Which IRB is overseeing this study?
Please provide the IRB Number:
IRB Number:
* must provide value
This box should only be checked if you are conducting a QI study.
If you are conducting a research study and/or have a non-hopkins IRB, you will be required to submit to either the School of Medicine or School of Public Health IRB for review.
If you have any questions, please contact Sarah Rubin, JHCP Research Program Manager srubin19@jhmi.edu
JHCP requires all projects to be approved or acknowledged by a Hopkins' IRB.
If you have any questions, please contact Sarah Rubin, JHCP Research Program Manager, at srubin19@jhmi.edu
When would you like to start your work with or at JHCP?
Today M-D-Y
Principal Investigator:
* must provide value
PI Email:
* must provide value
Research Administrator/Primary Contact: (If different from PI)
Will there be a JHCP Collaborator or Co-Investigator or JHCP Research Champion?
We encourage all projects to have a JHCP Co-I or Champion whenever possible. If you're interested in finding a JHCP collaborator, please contact Sarah Rubin, JHCP Research Program Manager at srubin19@jhmi.edu
* must provide value
Yes
No
Please provide JHCP Co-I/Research Champion name(s):
* must provide value
Please check the JHCP practices you would like to work with:
* must provide value
All JHCP Primary Care Sites (NOT including EBMC)
All JHCP Sites (includes ALL specialties, NOT including EBMC)
OB/GYN Practices (specify below)
Heart Care (specify below)
Surgery (specify below)
Pediatric Sites (specify below)
Annapolis
Bayview
Bowie
Brandywine
Canton Crossing
Charles County
Downtown Bethesda
EBMC (Please Note: to conduct research at EBMC will require a concurrent and separate process as it is no longer part of JH)
Frederick
Fulton
Germantown
Glen Burnie
Greater Dundalk
Green Spring Station
Hagerstown
Howard County
I Street
JHome
Montgomery Grove
North Bethesda
Odenton
Remington
Sibley Hospital Medicine
Urbana
Water's Edge
Westminster
White Marsh
Other Site(s) not listed (specify below)
Please select which Pediatric Practices you would like to work with:
Bowie (Family Practice)
Canton Crossing
EBMC (Please Note: to conduct research at EBMC will require a concurrent and separate process as it is no longer part of JH)
Glen Burnie (Family Practice)
Howard County
Odenton
Remington
Water's Edge
White Marsh
Please Select the OB/GYN practices you would like to work with:
Canton Crossing
EBMC (Please Note: to conduct research at EBMC will require a concurrent and separate process as it is no longer part of JH)
Howard County
Odenton
Remington
Please select which Heart Care site(s) you are recruiting from:
Bethesda
Chevy Chase
Rockville
Silver Spring
Please specify sites if you have checked off Surgery or Other above:
What do you wish to do at the JHCP site(s) you've selected?
* must provide value
Recruit Patients
Recruit Providers
Recruit Staff
Post Flyers
Review Charts
Request Data
Other (specify below)
If you have checked other above, please specify what you would like to do at JHCP:
Please upload the flyer you would like to post at JHCP.
* must provide value
Number of JHCP patients you plan on recruiting?
Number of JHCP Providers you plan on recruiting?
Number of JHCP Staff you plan on recruiting?
*This does not include providers*
Please select which of the following categories most closely describes your data request:
* must provide value
The project is not specifically looking at JHCP or breaking out JHCP data separately for analysis and reporting.
The project will be receiving JHCP encounter, location, or provider information but will not be assessing care quality, performance, or differences across sites or providers.
The study is requesting data that includes JHCP sites and provider identifiers and will be reporting quality, performance, or outcomes by site or provider.
N/A
How do you plan to recruit patients and/or providers or obtain information?
* must provide value
Retrospective review of medical records
Directed physical mailings to JHCP patients
Directed mailings to JHCP providers
General Advertisement
Literature/Flyer in waiting area
Literature for clinical staff
Provider/Social worker referral
Study staff will have table in waiting area
MyChart Recruitment
Other
If you have checked "Other," please specify your recruitment plan:
* must provide value
Can JHCP provide any other kind of support?
Educational Support
Administrative Support
Clinic Champion Support
Office Space
Clinical Space
Other
Please provide a short description of the support we can provide:
Please upload any other relevant files you would like to submit for review here.
Thank you for completing this form, a member of the JHCP Research Team will reach out to you soon!
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