Are you affiliated with the Department of Family Medicine at the University of Kansas Health System?
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Yes
No
What is your affiliation?
KUMC Student Other KUMC department TUKHS or other KUMC campus Frontiers affiliate (CMH, KCU, St. Lukes, UMKC) Other institution
Please specify.
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Position
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Department
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Email
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Are any Co-Investigators affiliated with the University of Kansas Health System Department of Family Medicine?
Yes
No
Name, affiliation, and email of any co-investigators
What type of study are you creating?
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Research Study Quality Improvement Study I'm not sure yet Other administrative data request
Please upload your IRB approved protocol.
Please upload your IRB approved QI determination letter.
Please describe your project purpose and specifics about the data request (inclusion/exclusion criteria etc)
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If you need help designing a project, please continue below. If you need help determining the type of study, please follow the link.
Has your Quality Improvement Request been approved by the IRB?
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Yes
No
If you need the form, it is below. If you need assistance with completing the form, please select 'project consult' in the request section below.
Do you have IRB approval?
Yes
No
What is the study number?
Who is involved in this research project?
specific nurses, PSRs, social workers etc
Who is involved in this QI project?
specific nurses, PSRs, social workers etc
What is the specific aim of the research study?
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Please briefly describe the proposed study.
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Do you have funding for this project?
Yes
No
Please list the funding source and total budget for this project.
Please describe any additional duties or work that the Family Medicine staff will be asked to take on as a result of this project or study.
ie additional paper work or training
Is there an opportunity for Family Medicine faculty and/or resident to be added to the study?
Yes
No
Please describe how FM faculty or residents could be involved with the project.
Please describe at least one direct benefit to the Family Medicine department, staff, and/or patient population as a result of this study.
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Please describe how this study will advance the delivery of care in family medicine?
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Which of the following are you requesting?
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No action needed, heads up only
Recruiting study participants from FM patient population
Project consult
Data
Project approval
Other
Please select all that are applicable
Which of the following are you requesting?
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Recruiting study participants from FM patient population
A collaborator from the Family Medicine department
Data
Other
Please select all that are applicable
Which of the following are you requesting?
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A collaborator from the Family Medicine department
Project Consult
Data
Other
Please select all that are applicable
Please describe your consult question(s).
Is compensation available for study participants?
Yes
No
Please describe the compensation.
What "other" are you requesting?
Which of the following are you requesting for the data consult?
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General data consult (discuss data sources etc)
Data clean (recommended for HERON data)
Basic statistical analysis
Other
Please select all that are applicable
Please describe the participant inclusion/exclusion criteria.
What data are you interested in? (demographics, A1c values, BMI, ICD codes, CPT codes, flowsheet data, quality metric data (CPC+ measurements, etc)
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What type of data do you need?
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Identified (must have IRB or QI approval), consist of MRNs, dates, address, contact information, SSN, account numbers, device numbers etc
Unidentified
I already have data
What date do you need the data by?
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Today M-D-Y minimum of two week turnaround
What date you would like the analysis to be completed?
Today M-D-Y minimum of two week turnaround
Are you applying for Maintenance of Certification credit with this project?
Yes
No
What is the estimated end date for the project?
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Today M-D-Y
Any other relevant information?
Submit
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