CTSI Service Request Form

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Please complete the form below to request CTSI services.

Please note: We are collecting this demographic information for internal use only, in order to determine investigators' baseline service usage at the CTSI. This is part of an ongoing continuous quality improvement project. Please reach out if any questions or concerns: ctsi@nyulangone.org

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Is this a REDCap Service Request?

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Date:

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M-D-Y

Your Last Name:

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Your First Name:

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Your Email Address:

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Your Kerberos ID:

What is your racial background? (Please check all that apply)

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American Indian/Alaska Native

African American

Asian

Hawaiian/Pacific Islander

White

Other

Do not wish to provide

Are you Hispanic (or Latino)?

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Yes

Do not wish to provide

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What gender do you identify as?

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Female

Male

Other (transgender, gender non-binary, intersex etc.)

Do not wish to provide

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Your Title:

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If other, please specify your title:

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What is your role on the current project?

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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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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

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Your Primary Affiliation:

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Please specify your other affiliation:

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Please specify your NYU Langone Health Institute/Center affiliation:

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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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What is your racial background? (Please check all that apply)

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American Indian/Alaska Native

African American

Asian

Hawaiian/Pacific Islander

White

Other

Do not wish to provide

Are you Hispanic (or Latino)?

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Yes

Do not wish to provide

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What gender do you identify as?

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Female

Male

Other (transgender, gender non-binary, intersex etc.)

Do not wish to provide

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PI Title:

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If other, please specify PI's title:

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Please specify your department at SoM:

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Please specify your division within Medicine:

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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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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

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PI Primary Affiliation:

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Please specify the PI's Other affiliation:

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Please specify the PI's department at SoM:

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Please specify the PI's division within Medicine:

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Please specify the PI's NYU Langone Health Institute/Center affiliation:

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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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Does the PI have any additional affiliations?

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Yes

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Please select the PI's additional affiliations (check all that apply):

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NYU School of Medicine/NYU Langone Health

NYU College of Dentistry

NYU College of Nursing

NYU Steinhardt

Wagner Graduate School of Public Service

Nelson Institute of Environmental Medicine (NYU Langone Health)

Institute of Reconstructive Plastic Surgery (NYU Langone Health)

NYU Perlmutter Cancer Center (NYU Langone Health)

NYU Neuroscience Institute (NYU Langone Health)

NYU Child Center (NYU Langone Health)

NYU Langone Orthopedic Hospital (formerly Hospital for Joint Diseases)

Rusk Institute (NYU Langone Health)

NYC Health + Hospitals , Bellevue

NYC Health + Hospitals, Kings County

NYC Health + Hospitals, Lincoln

NYC Health + Hospitals, Gouvernuer

NYC Health + Hospitals, Woodhull

NYC Health + Hospitals, Metropolitan

NYC Health + Hospitals, Coney Island

NYC Health + Hospitals, Coler - Goldwater

NYC Health + Hospitals Central Office

Other

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.

Attachment:Description of Services 8.14.23.pdf

CTSI Service/Resource you are requesting:

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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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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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Pediatric

Geriatric

Minority/Health Disparity (defined as Blacks/African Americans, Hispanics/Latinos, American Indians/Alaska Natives, Asian Americans, Native Hawaiians and other Pacific Islanders, socioeconomically disadvantaged populations, and rural populations)

None of the above

Do you have any collaborators for this research project?

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Yes

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First Co-Investigator's Name:

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First Co-Investigator's Title:

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Please specify the First Co-Investigator's other title:

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First Co-Investigator's Affiliation:

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Please specify the First Co-Investigator's NYU SoM Department:

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Please specify the First Co-Investigator's division within Medicine:

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Please specify the First Co-Investigator's NYU Langone Health Institute/Center affiliation:

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Please specify the First Co-Investigator's NYC Health + Hospitals facility affiliation:

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Please specify the First Co-Investigator's other affiliation:

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Second Co-Investigator's Name:

Second Co-Investigator's Title:

Please specify the Second Co-Investigator's other title:

Second Co-Investigator's Affiliation:

Please specify the Second Co-Investigator's NYU SoM Department:

Please specify the Second Co-Investigator's division within Medicine:

Please specify the Second Co-Investigator's NYU Langone Health Institute/Center affiliation:

Please specify the Second Co-Investigator's NYC Health + Hospitals facility affiliation:

Please specify the Second Co-Investigator's other affiliation:

Do you have a mentor for this research project?

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Yes

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Name of Mentor:

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Please tell us how you heard about these CTSI services and/or resources (CHECK ALL THAT APPLY):

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CTSI Monthly E-Newsletter

CTSI Website

Directly Involved in CTSI

Email Announcement

Office of Science and Research Website

Divison of Biostatistics Website

NYUBR Website

NYU Core Resources Website

Previously Used CTSI Services

Prior involvement with GCRC

Referred by Department Chair or Division Director

Referred by Mentor

Translational Research Education and Careers (TREC) Program

Word-of-mouth

Other

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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Grant Application (study design, power analysis, analysis plan for grant application)

Protocol Development

Data Analysis (actual statistical analysis of existing data)

Manuscript Preparation

Early Planning

Other

Specifically, what is your voucher request for? Check all that apply.

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Grant Application (study design, power analysis, analysis plan for grant application)

Protocol Development

Data Analysis (actual statistical analysis of existing data)

Manuscript Preparation

Early Planning

Other

If other, please specify:

When is the Sponsored Programs Administration (SPA) due date?

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M-D-Y

When is the sponsoring agency's due date?

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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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Federal granting agency

Foundation granting agency

Industry contract (company)

Internal funding

Other agency

No internal or external funding

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 (Please include an estimate of the cost):

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Are you aware if your Department or Division has biostatistical support?

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Yes

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Are you affiliated with any CTSI program?

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Yes No

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Are you affiliated with any CTSI program?

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Yes No

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If yes, please specify

Are you in a CTSI training program?

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Yes No

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Are you in a CTSI training program?

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Yes No

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If yes, please specify

Are you submitting a CTSI pilot application?

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Yes No

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Please upload a summary of your study here. Include any document that includes hypotheses, background, rationale, methods (whatever would be helpful for consultation).

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Upload file

Please upload a summary of your study here. Include any document that includes hypotheses, background, rationale, methods (whatever would be helpful for consultation).

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Upload file

Please describe the purpose of seeking a Research Studio:

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Grant submission

Publication submission

Implementation challenges associated with a project

Other

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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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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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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Upload file

How did you hear about the ResearchMatch Recruitment Tool?

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CTSI website

CTSI newsletter

Other website

Other newsletter

From a colleague who used it

Other

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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Would you like to host a ResearchMatch link for volunteers on your website?

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Yes

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Would you like to run a campaign to encourage volunteers in your disease focus/research area of interest?

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Yes

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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

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Since you specified "Other" for Type of Project, please explain:

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Are you requesting DataCore use?

Yes

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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):

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Community Engagement

Integrating Special Populations (Pediatric, Geriatric, Minority Health/Health Disparities)

Community-Based Participatory Research (CBPR)

Participant Recruitment and Retention in Research

Practice-based Research

Comparative Effectiveness Research

Cost-effectiveness Analysis

Behavioral Economics

Implementation Research

Dissemination Research

Social Epidemiology

Other

Please specify other:

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What is your funding source? Include pending and awarded grants.

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Federal granting agency

Foundation granting agency

Industry contract (company)

Internal funding

Other agency

No internal or external funding

Please specify the other agency

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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.

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Briefly list the questions for which you are seeking consultation:

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Please indicate the timeline for your request:

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Immediately

1-3 months from now

3-6 months from now

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Please upload a document that summarizes the study, including if possible aims, hypotheses, methods, etc.

* must provide value

Upload file

Please indicate the area in which you requesting Recruitment and Retention Consultation Services (CHECK ALL THAT APPLY):

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Participant Recruitment and Retention in Research - General (Planning, Feasibility, Retention)

Patient Advisory Council for Research (PACR)

Patient Recruitment though ResearchMatch

Patient Recruitment through MyChart

Patient Recruitment through advertising clinical trials on social media platforms

Message templates for contacting study participants

Recruitment e-Book

Other

Please specify other:

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What is your funding source? Include pending and awarded grants.

* must provide value

Federal granting agency

Foundation granting agency

Industry contract (company)

Internal funding

Other agency

No internal or external funding

Please specify the other agency

* must provide value

Briefly list the questions for which you are seeking consultation:

* must provide value

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Please indicate the timeline for your request:

* must provide value

Immediately

1-3 months from now

3-6 months from now

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Please upload a document that summarizes the study, including if possible aims, hypotheses, methods, etc.

* must provide value

Upload file

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

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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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Please specify other:

Will this data be transferred outside NYC H+H?

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Yes

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Please describe how and why the data will be transferred:

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Will the data be reported publicly?

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Yes

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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?

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Yes

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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:

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Please specify what your preferred data source is:

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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

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Since it is based on an existing report, please specify:

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Please specify the NYC Health + Hospitals Facility (check all that apply):

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Bellevue Hospital Center

Coler-Goldwater Memorial Hospital

Coney Island Hospital

Cumberland D&TC

Dr. Susan Smith McKinney Nursing

East New York D&TC

Elmhurst Hospital Center

Gouverneur D&TC

Gouverneur Nursing Facility

Harlem Hospital Center

Jacobi Medical Center

Kings County Hospital Center

Lincoln Hospital

Metropolitan Hospital Center

Morrisania D&TC

North Central Bronx Hospital

Queens Hospital Center

Renaissance D&TC

Sea View Hospital

Segundo Ruiz Belvis D&TC

Woodhull Hospital

Other

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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Any other information:

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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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