Today M-D-Y
Project Deadline
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Today M-D-Y Please note that the deadline should be no less than one week from the project request time.
The selected date is fewer than 5 business days. Please select a difference date.
Your First Name
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Your Last Name
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Your E-mail Address
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BCVI will only communicate via institutional e-mail addresses (e.g. northwestern.edu, luriechildrens.org, nm.org, etc.) for Feinberg and its affiliates. Please DO NOT enter a non-institutional e-mail address (e.g. gmail.com, yahoo.com) if you are affiliated with Northwestern or its partners.
Please enter your institutional e-mail address (e.g. northwestern.edu, luriechildrens.org, nm.org, etc.) Your Contact Phone/Pager Number
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Are you the PI on this project?
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Yes
No
Principal Investigator First Name
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Principal Investigator Last Name
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Principal Investigator Email
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BCVI will only communicate via institutional e-mail addresses (e.g. northwestern.edu, luriechildrens.org, nm.org, etc.) for Feinberg and its affiliates. DO NOT enter a non-institutional e-mail address (e.g. gmail.com, yahoo.com) if you are affiliated with Northwestern or its partners.
Please enter your institutional e-mail address (e.g. northwestern.edu, luriechildrens.org, nm.org, etc.)
PI Phone/Pager Number
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Primary Institution Affiliation
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Northwestern Memorial HealthCare
NU - Feinberg School of Medicine
NU - Non-Feinberg (e.g. McCormick, Weinberg, The Graduate School, Communication)
Ann and Robert H. Lurie Children's Hospital
Shirley Ryan AbilityLab
Robert H. Lurie Comprehensive Cancer Center
External
Other
If "Other", please specify
Project Title
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Short Title
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The short title should be under 20 characters and should not include spaces.
What is clinical area for this request?
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Advanced Heart Failure / Transplant Adult Cardiac Surgery Cardiac Imaging Electrophysiology Interventional Cardiology Pulmonary Cardiology Transcatheter Valve Vascular General Cardiology or Other
Is this a new request?
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Yes
No
This request is in addition to an existing request dated:
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Today M-D-Y
A summary may be attached below as well.
Do not upload files or data that include protected health information or patient identifiers. After review of your request, a member of the CTU will contact you to arrange secure transfer of files, if necessary.
Yes
No
Is this request part of an IRB approved project?
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Yes
No
IRB Study Number
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Total number of subjects approved for review.
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This is the number of participants (or samples) listed in IRB approved protocol.
Is this project managed by BCVI?
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Yes
No
If this project is not managed by BVCI Clinical Trials Unit, upload a copy of your approved protocol
If this project is not managed by BVCI Clinical Trials Unit, upload a copy of your IRB approval letter
Service requested - check all that apply
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Specify the other type of request
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Purpose of Data RequestQuality Assurance Data requested for QA purposes can only be used for quality assurance initiatives. Individuals requesting data for QA purposes acknowledge they have no intent on publishing findings. Feasibility Requests Only # of cases/events are provided. Research Requests Research requests are intended for presentation or publication. Aggregate data/summary reports will be provided by a CTU biostatistician. For non-aggregate data separate IRB approval must be obtained and provided to the CTU; IRB application should indicate that data will be obtained from the Clinical Trials Unit Cardiovascular Database. Data will not be provided until proof of IRB approval is provided to the CTU.
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Quality Assurance/Improvement Feasibility Research
Are raw data expected for this project?
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Yes, raw data are needed for internal (NM/NU) use only Yes, raw data are needed and will be shared outside of NM/NU No, aggregated data or summary statistics only
In order to send raw data outside of NM/NU, a DUA must be executed. Please upload a copy of the DUA or contact the CTU for further discussion
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Start Date of data being requested
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Today M-D-Y If requested for research purposes the date range should reflect dates indicated in your IRB application and approved protocol.
End Date of data being requested
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Today M-D-Y If requested for research purposes the date range should reflect dates indicated in your IRB application and approved protocol.
Today M-D-Y Indicate date data is needed by. Allow a minimum of 5 business days. Requests will be processed in order received.
The selected date is fewer than 5 business days. Please select a difference date.
Tissue/Blood Sample Information
Which type of sample(s) do you need?
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Which type of tissue sample(s) do you need?
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Specify the other type of tissue you are requesting.
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Number of patient cases needed (per type of tissue sample)
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Number of patient cases needed for blood samples
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Today M-D-Y Indicate date specimens are needed. Allow minimum of 5 business days.
Subject Limitations (i.e., Inclusion/Exclusion criteria)
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Statistical Support Request
Statistical Support Request
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Specify the other type of statistical support requested
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My expectations for this project are (check all that apply):
If "Other," please specify
Are there statistical programs in use?
If "Other", please specify
Are there other computer programs in use?
If "Other", please specify
Current or new grant?
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Current
New
What agency is the grant being submitted to?
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NIH
NSF
Foundation
Other
What type of grant is this?
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Mentored career development award (e.g., NIH K-level grant, institutional KL2, Foundation Career)
Research grant (e.g., NIH R-level grant or similar - PCORI, DOD, NSF)
Program or center grant (e.g., NIH P or U)
Foundation grant not covered above (e.g., AHA, ASCO, Susan G Komen, etc.)
Industry sponsored grant
Grant Submission Deadline
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Today M-D-Y
Is this a request for a letter of support only?
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Yes
No
Specific Granting Agency/Foundation
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Title of Grant Application
BCVI recommends that new grant submissions requiring more than a letter of support be requested 6-8 weeks before the submission deadline.
Is this project for a FDA regulated study that will comply with 21 CFR Part 11?
Yes
No
Specify the other form of REDCap support requested
My expectations for this project are (check all that apply):
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