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/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

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PRtpcDx2moqKzuc6Zg6WeepLxsNKhbKkVIfWP72J24qkqWrQyNhD3oixWqwIEAiLVHienSqX5oZQj

JHCP Research Project Application - NEW!

Hello!
Thank you for taking the time to fill out this short questionnaire. The JHCP Research Department looks forward to collaborating with you on your research project. Please feel free to reach out to someone on our team for help with this form, questions about participating with JHCP or to talk strategy about research implementation at any of our sites. We are here to help!

Johns Hopkins Community Physicians, INC. (JHCP)
Research Director: Wendy Bennett, MD, MPH
Research Program Manager: Sarah Rubin srubin19@jhmi.edu
Research Program Coordinator: Kate Holzhauer kholzha1@jhu.edu

What to Expect:
After submitting this form a member of the study team will contact you.
Then, your study will be reviewed by the JHCP Research and Projects Committee. The goal of this review is to ensure the success of your project by facilitating collaboration between your research team and JHCP sites.

We are looking forward to working with you!

JHCP Research and Projects Committee

Admin Only Information

JHCP Research ID Number

JHCP Review Date

M-D-Y

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.

D-M-Y

Review type

None

RPC

RET/Email

Research Director

BMS

Approved?

Yes

reset

IRB Status

Approved

Acknowledged

Pre-IRB

Under review

Lapsed

Terminated

reset

Is this project still enrolling?

Yes

reset

Date of status update

M-D-Y

Notes, Comments, Concerns

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Study Title:

* must provide value

Is this a resident led project?

Yes

reset

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

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Calc of IRB field
(hidden from survey, used for "default" on second survey)

View equation

Which IRB is overseeing this study?

Please provide the IRB Number:

Hopkins 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?

M-D-Y

Principal Investigator:

* must provide value

PI Email:

* must provide value

Research Administrator/Primary Contact: (If different from PI)

Primary Contact E-mail:

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

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Please provide JHCP Co-I/Research Champion name(s):

* must provide value

Expand

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:

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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:

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Please upload the flyer you would like to post at JHCP.

* must provide value

Upload file

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

reset

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

Expand

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:

Expand

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!

Upload file

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.