Is this a REDCap Service Request?
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Date:
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Today M-D-Y
Your Last Name:
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Your First Name:
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Your Email Address:
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The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
What is your racial background? (Please check all that apply)
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Are you Hispanic (or Latino)?
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Yes
No
Do not wish to provide
What gender do you identify as?
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Female
Male
Other (transgender, gender non-binary, intersex etc.)
Do not wish to provide
Your Title:
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Full Professor Associate Professor Assistant Professor Instructor Medical Fellow PhD Fellow Other
If other, please specify your title:
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What is your role on the current project?
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Principal Investigator (PI) Project Director/Administrator Research Fellow Research Assistant or other Research Staff Other
If other, please specify your role:
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Please indicate the stage of your research career:
New Investigator = have not received a substantial independent research award as a PI; may have received a Small Grant (R03) or an Exploratory/Developmental Research Grant Award (R21)
Established Investigator = awarded an external, peer-reviewed Research Project Grant (RPG) or Program Project Grant (PPG) from a Federal or non-Federal source (e.g. R01, P01)
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New Investigator Established Investigator Not applicable
Are you within 10 years of completing a terminal research degree OR within 10 years of completing medical residency (or the equivalent)?
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Yes
No
Your Primary Affiliation:
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NYU School of Medicine (SoM) NYU Langone Health (NYU Orthopedic, Hassenfeld Children's, NYU Brooklyn, NYU Winthrop) NYU Langone Health Institute/Center NYC Health + Hospitals NYU College of Dentistry NYU College of Nursing NYU Steinhardt Wagner Graduate School of Public Service Other
Please specify your other affiliation:
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Please specify your NYU Langone Health Institute/Center affiliation:
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Nelson Institute of Environmental Medicine Institute of Reconstructive Plastic Surgery NYU Cancer Center NYU Neuroscience Institute NYU Child Study Center Rusk Rehabilitation Other
If other, please specify your NYU Langone Health Institute/Center affiliation.
PI Last Name:
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PI First Name:
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PI Email Address:
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PI Kerberos ID:
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The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
What is your racial background? (Please check all that apply)
* must provide value
Are you Hispanic (or Latino)?
* must provide value
Yes
No
Do not wish to provide
What gender do you identify as?
* must provide value
Female
Male
Other (transgender, gender non-binary, intersex etc.)
Do not wish to provide
PI Title:
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Full Professor Associate Professor Assistant Professor Instructor Medical Fellow PhD Fellow Other
If other, please specify PI's title:
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Please specify your department at SoM:
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Anesthesiology Biochemistry and Molecular Pharmacology Cardiothoracic Surgery Cell Biology Child and Adolescent Psychiatry Dermatology Ehrman Medical Library Emergency Medicine Environmental Medicine Forensic Medicine Medicine Microbiology Neurosurgery Neurology Obstetrics and Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physiology and Neuroscience Plastic Surgery Population Health Psychiatry Radiation Oncology Radiology Rehabilitation Medicine Surgery Urology
Please specify your division within Medicine:
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Cardiology Endocrinology Gastroenterology General Internal Medicine Geriatric Medicine and Palliative Care Hematology and Medical Oncology Infectious Diseases and Immunology Medical Humanities Nephrology Pulmonary, Critical Care, and Sleep Medicine Rheumatology Translational Medicine
Please indicate the stage of the PI's research career:
New Investigator = have not received a substantial independent research award as a PI; may have received a Small Grant (R03) or an Exploratory/Developmental Research Grant Award (R21)
Established Investigator = awarded an external, peer-reviewed Research Project Grant (RPG) or Program Project Grant (PPG) from a Federal or non-Federal source (e.g. R01, P01)
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New Investigator Established Investigator
Is the PI within 10 years of completing a terminal research degree OR within 10 years of completing medical residency (or the equivalent)?
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Yes
No
PI Primary Affiliation:
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NYU School of Medicine (SoM) NYU Langone Health (NYU Orthopedic, Hassenfeld Children's, NYU Brooklyn, NYU Winthrop) NYU Langone Health Institute/Center NYC Health + Hospitals NYU College of Dentistry NYU College of Nursing NYU Steinhardt Wagner Graduate School of Public Service Other
Please specify the PI's Other affiliation:
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Please specify the PI's department at SoM:
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Anesthesiology Biochemistry and Molecular Pharmacology Cardiothoracic Surgery Cell Biology Child and Adolescent Psychiatry Dermatology Ehrman Medical Library Emergency Medicine Environmental Medicine Forensic Medicine Medicine Microbiology Neurosurgery Neurology Obstetrics and Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physiology and Neuroscience Plastic Surgery Population Health Psychiatry Radiation Oncology Radiology Rehabilitation Medicine Surgery Urology
Please specify the PI's division within Medicine:
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Cardiology Endocrinology Gastroenterology General Internal Medicine Geriatric Medicine and Palliative Care Hematology and Medical Oncology Infectious Diseases and Immunology Medical Humanities Nephrology Pulmonary, Critical Care, and Sleep Medicine Rheumatology Translational Medicine
Please specify the PI's NYU Langone Health Institute/Center affiliation:
* must provide value
Nelson Institute of Environmental Medicine Institute of Reconstructive Plastic Surgery NYU Cancer Center NYU Neuroscience Institute NYU Child Study Center Rusk Rehabilitation Other
If other, please specify the PI's NYU Langone Health Institute/Center affiliation:
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Please specify the PI's NYC Health + Hospitals facility affiliation:
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Bellevue Kings County Lincoln Gouvernuer Woodhull Metropolitan Coney Island Coler- Goldwater NYC Health + Hospitals Central Office
Does the PI have any additional affiliations?
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Yes
No
Please select the PI's additional affiliations (check all that apply):
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Please specify the PI's additional affiliation:
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Please provide an additional contact (full name and email address/phone number) from your team, i.e., study coordinator, project manager, etc.
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Please see the attached document for a short description of services/resources that can be requested via this form.
CTSI Service/Resource you are requesting:
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Biomedical/Clinical Research Informatics OR DataCore Request Consultation in Biostatistics, Epidemiology, and Study Design (BERD) Consultation in Clinical Research Resources Consultation in Clinical and Translational Research Ethics Consultation in Community Engagement and Population Health Research (CEPHR) OR Consultation in Integrating Special Populations (ISP) Consultation in Survey Design Consultation in Evaluation Best Practices Help Finding Research Collaborators NYC Health + Hospitals Clinical Data Service Center (access to NYC H+H data) Consultation in Recruitment and Retention (RRC) Patient Recruitment Assistance using ResearchMatch Research Concierge Services (help navigating research at NYU and CTSI resources/services) Research Studio (in-depth study review and critique) Trial Innovation Network (TIN Trials) ACT Network Wet lab services for dry/clinical researchers Voucher Request Other
Please specify the other service you are requesting:
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Please describe the nature of your request/need for CTSI services:
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What is the title of your research project?
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What is the status of this research project?
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Early Planning/Protocol Development Grant Writing Ready To Process Samples Analysis of Existing Data Other
Please specify the status of your project:
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Does your research project involve any of the following populations (check all that apply):
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Do you have any collaborators for this research project?
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Yes
No
First Co-Investigator's Name:
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Last, First
First Co-Investigator's Title:
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Full Professor Associate Professor Assistant Professor Instructor Medical Fellow PhD Fellow Other
Please specify the First Co-Investigator's other title:
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First Co-Investigator's Affiliation:
* must provide value
NYU School of Medicine (SoM) NYU Langone Health (NYU Orthopedic, Hassenfeld Children's, NYU Brooklyn, NYU Winthrop) NYU Langone Health Institute/Center NYC Health + Hospitals NYU College of Dentistry NYU College of Nursing NYU Steinhardt Wagner Graduate School of Public Service Other
Please specify the First Co-Investigator's NYU SoM Department:
* must provide value
Anesthesiology Biochemistry and Molecular Pharmacology Cardiothoracic Surgery Cell Biology Child and Adolescent Psychiatry Dermatology Ehrman Medical Library Emergency Medicine Environmental Medicine Forensic Medicine Medicine Microbiology Neurosurgery Neurology Obstetrics and Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physiology and Neuroscience Plastic Surgery Population Health Psychiatry Radiation Oncology Radiology Rehabilitation Medicine Surgery Urology
Please specify the First Co-Investigator's division within Medicine:
* must provide value
Cardiology Endocrinology Gastroenterology General Internal Medicine Geriatric Medicine and Palliative Care Hematology and Medical Oncology Infectious Diseases and Immunology Medical Humanities Nephrology Pulmonary, Critical Care, and Sleep Medicine Rheumatology Translational Medicine
Please specify the First Co-Investigator's NYU Langone Health Institute/Center affiliation:
* must provide value
Nelson Institute of Environmental Medicine Institute of Reconstructive Plastic Surgery NYU Langone Perlmutter Cancer Center NYU Langone Neuroscience Institute NYU Langone Child Study Center Rusk Rehabilitation Other
Please specify the First Co-Investigator's NYC Health + Hospitals facility affiliation:
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Bellevue Kings County Lincoln Gouvernuer Woodhull Metropolitan Coney Island Coler- Goldwater NYC Health + Hospitals Central Office
Please specify the First Co-Investigator's other affiliation:
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Second Co-Investigator's Name:
Last, First
Second Co-Investigator's Title:
Full Professor Associate Professor Assistant Professor Instructor Medical Fellow PhD Fellow Other
Please specify the Second Co-Investigator's other title:
Second Co-Investigator's Affiliation:
NYU School of Medicine (SoM) NYU Langone Health (NYU Orthopedic, Hassenfeld Children's, NYU Brooklyn, NYU Winthrop) NYU Langone Health Institute/Center NYC Health + Hospitals NYU College of Dentistry NYU College of Nursing NYU Steinhardt Wagner Graduate School of Public Service Other
Please specify the Second Co-Investigator's NYU SoM Department:
Anesthesiology Biochemistry and Molecular Pharmacology Cardiothoracic Surgery Cell Biology Child and Adolescent Psychiatry Dermatology Ehrman Medical Library Emergency Medicine Environmental Medicine Forensic Medicine Medicine Microbiology Neurosurgery Neurology Obstetrics and Gynecology Ophthalmology Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physiology and Neuroscience Plastic Surgery Population Health Psychiatry Radiation Oncology Radiology Rehabilitation Medicine Surgery Urology
Please specify the Second Co-Investigator's division within Medicine:
Cardiology Endocrinology Gastroenterology General Internal Medicine Geriatric Medicine and Palliative Care Hematology and Medical Oncology Infectious Diseases and Immunology Medical Humanities Nephrology Pulmonary, Critical Care, and Sleep Medicine Rheumatology Translational Medicine
Please specify the Second Co-Investigator's NYU Langone Health Institute/Center affiliation:
Nelson Institute of Environmental Medicine Institute of Reconstructive Plastic Surgery NYU Langone Health Perlmutter Cancer Center NYU Langone Health Neuroscience Institute NYU Langone Health Child Study Center Rusk Rehabilitation Other
Please specify the Second Co-Investigator's NYC Health + Hospitals facility affiliation:
Bellevue Kings County Lincoln Gouvernuer Woodhull Metropolitan Coney Island Coler- Goldwater NYC Health + Hospitals Central Office
Please specify the Second Co-Investigator's other affiliation:
Do you have a mentor for this research project?
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Yes
No
Name of Mentor:
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Last, First
Please tell us how you heard about these CTSI services and/or resources (CHECK ALL THAT APPLY):
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Since you identified "Other" for for how you heard about the CTSI Services and/or Resources, please specify:
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TO ALL INVESTIGATORS:
• For all service requests , the NYUBR/CTSI offers a one-hour and/or initial consultation to provide general suggestions and guidance in study design, protocol development and/or data analysis.
• During the initial consultation, the investigator will meet with faculty in the Division of Biostatistics in the Department of Population Health.
• For the meeting, please bring a brief written description of the aims of your analysis, a related paper on your subject (if possible), and, if appropriate, your database on a laptop.
• ALL DATA MUST BE DE-IDENTIFIED.
• If additional work and follow-up meetings are needed, the Biostatistics faculty will estimate the level of effort. The investigator can request an appropriate level of support for the level of biostatistics from the CTSI Resource Allocation Program (RAP) in the proposed study budget.
GRANT APPLICANTS:
• If the consultation is to develop an application for extramural funding and the investigator agrees to collaborate with the biostatistics faculty, the faculty member should be listed as Co-Investigator with appropriate level of effort (FTE) for the faculty and/or staff required for the conduct of the study.
Specifically, what do you need statistical and/or study design consulting for? Check all that apply.
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Specifically, what is your voucher request for? Check all that apply.
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If other, please specify:
When is the Sponsored Programs Administration (SPA) due date?
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Today M-D-Y
When is the sponsoring agency's due date?
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Today M-D-Y
Which agency are you applying to?
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What is the funding status of your study? Include pending and awarded grants.
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Is there current funding? If so, please state the grant number & funding agency
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Briefly list the questions for which you are seeking consultation:
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Briefly list what you are requesting a voucher for:
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Are you aware if your Department or Division has biostatistical support?
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Yes
No
Are you affiliated with any CTSI program?
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Yes No
Are you affiliated with any CTSI program?
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Yes No
Are you in a CTSI training program?
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Yes No
Are you in a CTSI training program?
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Yes No
Are you submitting a CTSI pilot application?
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Yes No
Please upload a summary of your study here. Include any document that includes hypotheses, background, rationale, methods (whatever would be helpful for consultation).
* must provide value
Please upload a summary of your study here. Include any document that includes hypotheses, background, rationale, methods (whatever would be helpful for consultation).
* must provide value
Please describe the purpose of seeking a Research Studio:
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If other, please specify:
Please provide a brief paragraph describing what you hope to get out of a research studio including information about your project and the specific issues with which you are struggling:
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Please provide the name of the funding agency (including if NIH, institute and study section):
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Please provide the due date of the grant submission:
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Today M-D-Y
If seeking help with submitting a publication, please provide the name of the journal (or possible journals):
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Please provide the estimated due date of the publication submission:
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Today M-D-Y
If seeking help with implementation issues, please describe:
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Please upload a document that summarizes the research project here (e.g. research summary, specific aims, abstract).
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How did you hear about the ResearchMatch Recruitment Tool?
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Please specify the other source:
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List the study you would like to enroll in ResearchMatch:
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Please provide the IRB #:
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Please indicate the best person to contact within your department regarding recruitment outreach coordination with ResearchMatch.
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Name, Title, Email
Would you like to host a ResearchMatch link for volunteers on your website?
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Yes
No
Would you like to run a campaign to encourage volunteers in your disease focus/research area of interest?
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Yes
No
Type of Project:
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DNA/RNA Sequencing
Microarray
Clinical Database
High Performance Computing
Information Retrieval/Bibliometrics
Proteomics
Microbiomics
Data Integration/Network Science
Other
Since you specified "Other" for Type of Project, please explain:
* must provide value
Are you requesting DataCore use?
Yes
No
If yes, please use this form to request DataCore services: https://servicecatalog.nyumc.org/Pages/DataCore-Request.aspx
Please indicate the area in which you requesting Community Engagement and Population Health Research (CEPHR) OR Integrating Special Populations (ISP) Consultation Services (CHECK ALL THAT APPLY):
* must provide value
Please specify other:
* must provide value
What is your funding source? Include pending and awarded grants.
* must provide value
Please specify the other agency
* must provide value
If your project has no extramural funding, briefly explain how the requested services for this pilot project will lead to submission for extramural funding of a complete translational or clinical study. Please note: subsidized services provided by the CTSI Cores are subject to available resources.
* must provide value
Briefly list the questions for which you are seeking consultation:
* must provide value
Please indicate the timeline for your request:
* must provide value
Immediately
1-3 months from now
3-6 months from now
Please upload a document that summarizes the study, including if possible aims, hypotheses, methods, etc.
* must provide value
Please indicate the area in which you requesting Recruitment and Retention Consultation Services (CHECK ALL THAT APPLY):
* must provide value
Please specify other:
* must provide value
What is your funding source? Include pending and awarded grants.
* must provide value
Please specify the other agency
* must provide value
Briefly list the questions for which you are seeking consultation:
* must provide value
Please indicate the timeline for your request:
* must provide value
Immediately
1-3 months from now
3-6 months from now
Please upload a document that summarizes the study, including if possible aims, hypotheses, methods, etc.
* must provide value
NYC Health + Hospitals Clinical Data Request
Please complete the NYC Health + Hospitals CTSI Data Request Form found here:
https://openredcap.nyumc.org/apps/redcap/surveys/index.php?s=YE9TKDY4LX
What is the report required for?
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Management/Clinical Operations
Quality Assurance
Research
Other
Since you identified the report being required for research purposes, please provide the:
- IRB number
- NYC Health + Hospitals approval number
- Source of funding
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Will this data be transferred outside NYC H+H?
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Yes
No
Please describe how and why the data will be transferred:
* must provide value
Will the data be reported publicly?
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Yes
No
Please describe how and why data will be reported publicly:
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Will the data being collected be used now or future for commercial purposes?
* must provide value
Yes
No
Please describe how and why the data could be used for commercial properties:
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Please describe how the security and confidentiality of the data be protected, maintained and retained:
* must provide value
Please specify what your preferred data source is:
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Data Warehouse Patient Registry Other
Please describe more specifically which kinds of data you would like to obtain?
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Is this request based on an existing report?
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Yes
No
Since it is based on an existing report, please specify:
* must provide value
Please specify the NYC Health + Hospitals Facility (check all that apply):
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Please specify other:
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Please provide a description of the report:
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List the data fields to be included in the report (e.g MRN, Name, DOB, etc.):
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List the criteria/conditions of the report (eg visit type = clinic patient and outpatient or HgbA1c result value > 7):
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In what format would you like the report (e.g. xls, delimited text, etc.)?
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Will this report be run regularly? If so, how often (e.g. monthly, yearly, quarterly, as needed)?
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Describe your experiment:
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Do you need specimens? What type?
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What is your scientific question?
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What test(s) do you propose to run to answer the question?
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How many specimens do you anticipate will be processed?
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