Application Start Date Today M-D-Y
Please select one of the following:* must provide value
Initial Application
Annual Renewal Application
CWRU Medical Student Application (Initial and Renewal)
*** NOTE: THIS APPLICATION IS INTERACTIVE BASED ON YOUR SELECTIONS. DO NOT SKIP THIS QUESTION. ***
First Name* must provide value
Last Name* must provide value
Middle Name
Other name by which you have been known
Last 4 digits of your Social Security Number* must provide value
Date of birth* must provide value
Today M-D-Y
Gender* must provide value
Male Female
City, State, Country of Birth* must provide value
Citizenship* must provide value
United States Other
If not a United States citizen, what is your permanent resident or visa status at the present time?
Email address* must provide value
Home address (number/street, city, state, zip)* must provide value
I am affiliated with the following institutions (check all that apply):* must provide value
Case Western Reserve University
Case Western Reserve University Kelly Services Employee
MetroHealth Medical Center
Louis Stokes Cleveland VA Medical Center
Ursuline College
UH Affiliated Hospitals ( including Southwest General, Lake Health, & Firelands Regional Medical Center)
Other *
Kent State Nursing Students
Cleveland State Nursing Students
*If your institution is not listed above, please contact UHResearchCredentailing@UHhospitals.org before completing an applicaiton.
Please upload a current copy your ID issued by the institution that you have selected above. * must provide value
UH Affiliated Hospital Name
Please provide the name of the academic institution
Current Position/Title held at each affiliated institution that you have selected above* must provide value
Do you hold a position as an administrator, director, or trustee of any hospital, health care system and/or health care entity? Yes No
By whom?
Describe your relationship
Are you currently employed by, compensated by, or contracted with any hospital, health care system and/or health care entity?* must provide value
Yes No
By whom?
Describe your relationship
Name of your Employer -OR- Educational Institution* must provide value
Please enter your Department, Division or School.
Position currently held* must provide value
Office Address (number/street, city, state, zip)* must provide value
Office phone* must provide value
Office manager* must provide value
Requested Appointment Category* must provide value
Research Faculty (for MDs and/or PhDs; must also be a member of the faculty of CWRU)
Research Associate
I have completed a required Criminal Background Check. * must provide value
Yes
No
* Please refer to page 6 of the SOP for instructions on how to obtain a background check.
Upload background check if completed by another organization than through www.CorporateScreening.com or by UH (If applicable)
***PLEASE NOTE that if your background check on file with UH Staffing Compliance is older than 5 years old, you will be asked to provide an updated background check.
A background verification is required with the School of Medicine. * must provide value
This is my first application and I have submitted the "Student Letter Request Form" per the instructions above.
I have previously been UH Research Credentialed and my background check verification is already on file with UH Research Credentialing.
*If a background check verification is not on file you will be notified and your application will not be approved.
I acknowledge and hereby authorize Case Western Reserve University School of Medicine to provide my criminal background check to University Hospitals Clinical Research Center.* must provide value
Yes
No
UH Department you are affiliated with:* must provide value
Anesthesiology and Perioperative Medicine Biology/Epidemiology and Biostatistics Bioethics Case Comprehensive Cancer Center Case Center for Imaging Research Center for Global Health and Diseases Center for Regenerative Medicine Dahms Clinical Research Unit Dentistry Dermatology Emergency Medicine Family Medicine and Community Health Genetics Medicine Music Therapy Neurology Neurological Surgery Nursing Ophthalmology Orthopedics Orthopedics- Pediatrics Otolaryngology/Head and Neck Surgery Pathology Pediatrics Pharmacy Plastic Surgery Psychology Psychiatry Quality Center Services Radiation Oncology Radiology Rehabilitation Services Reproductive Biology (Obstetrics and Gynecology) Surgery Urology Research Health Analytics & Informatics
UH Department of Medicine Division you are associated with:* must provide value
Cardiovascular Medicine Clinical Pharmacology Endocrinology Gastroenterology General Internal Medicine and Geriatrics Hematology/Oncology Infectious Diseases and HIV Medicine Nephrology and Hypertension Pulmonary and Critical Care Rheumatology Translational Science Unit and Cardiovascular Imaging Core Laboratory
UH Department of Pediatric Division you are associated with:* must provide value
Allergy & Immunology Cardiology and Cardiothoracic Surgery Dentistry Center for Child Health and Policy Dermatology Developmental & Behavioral, Psychology Emergency Medicine Endocrinology Epidemiology and Biostatistics Epilepsy Gastroenterology General Academic & Adolescent Medicine Genetics Hematology and Oncology Infectious Disease, Rheumatology, Global Child Health Neonatology Nephrology Neurology Orthopaedics Pharmacology and Critical Care Pulmonology Sports Medicine Surgery
Select Department Administrator from the Department of Anesthesiology and Perioperative Medicine * must provide value
Cindy Patrzyk
Select Department Administrator from Biology/Epidemiology and Biostatistics * must provide value
Wendy Lachowski
Ann Nevar
Select Department Administrator from Bioethics * must provide value
Barb Daly
Select Department Administrator from the Case Comprehensive Cancer Center* must provide value
Dean Robertson
Josephine Chan
Shawn Smith (Rad/Onc)
Select Department Administrator from Dentistry* must provide value
Kathy Sanniti
Erin Rose Glending
Select Department Administrator from the Department of Dermatology* must provide value
Erich Zirzow
Mary Consolo
Amanda Davies
Select Department Administrator from the Department of Emergency Medicine* must provide value
Dildred Houston
Select Department Administrator from the Department of Family Medicine and Community Health * must provide value
Donna Bentley
Deborah Pride
Kimberly Sanders
Select Department Administrator from the Department of Genetics * must provide value
Wendy Lachowski
Select Department Administrator from the Department of Neurology* must provide value
Eleanor Goldfarb
David Haney
Select Department Administrator from the Department of Neurological Surgery * must provide value
Eleanor Goldfarb
Jennifer Tobias
David Haney
Select Department Administrator from Nursing * must provide value
Sara Douglas
For Nursing Research you must select the administrator for the department the study is associated with.
Select Department Administrator from the Department of Ophthalmology* must provide value
Bill Schneider
Allison Kaput
Select Department Administrator from the Department of Orthopedics* must provide value
Diane DeRubertis
For Peds Ortho, please select Pediatrics as the department, Orthopedics as the Division, and Jason Pellman as the administrator. Thank you!
Select Department Administrator from the Department of Otolaryngology/Head and Neck Surgery* must provide value
Bridget Patrick
Lakeeta Shaw
Select Department Administrator from the Department of Pathology * must provide value
Don Landek
Ruth Natali
Select Department Administrator from the Department of Plastic Surgery* must provide value
Lisa DiNardo
Select Department Administrator from the Department of Psychiatry* must provide value
Kristen Cassidy
Select Department Administrator from the Department of Radiation Oncology* must provide value
Shawn Smith
Dean Robertson
Select Department Administrator from the Department of Radiology* must provide value
Philipp Graner
Victoria Uram
Select Department Administrator from the Department of Reproductive Biology (Obstetrics and Gynecology)* must provide value
Wendy Lachowski
Select Department Administrator from the Department of Surgery* must provide value
Ryan Jastromb
Bridget Patrick
Select Department Administrator from the Department of Urology* must provide value
Zach Maher
Rosemary Brewka
Select Department Administrator from the Department of Pharmacy Ronald Cowan
Select Department Administrator from the Department of Pediatrics* must provide value
Patrick Holzheimer
Sandra Costello
Lisa Beachler
Amy Knott
Susan Wood
Ann Nevar
Brian Luben
Jennifer Fitch
Jason Pellman
Rebecca Marie Baas
Susan Vicol
Alicia Trybus
Erin Figueira
Select Department Administrator from the Department of Medicine* must provide value
Steve Myers
Stacey Mazzurco
Dean Robertson
Debbie Rudisille
Mary Wenzel
Mike Bruno
LeighAnn Ferrall
Carmeline Jefferson
Josephine Chan
Richard Sukeena
Abigail Williams
Jill Barnholtz-Sloan
Andrea Kovatch
Jane Baum
Shawn Smith
Rebecca Kahl
Select Department Administrator from the Department of Rehabilitation Services Karen Bitzer
Select Department Administrator from the Dahms Clinical Research Unit Megan O'Neill Miller
Select Department Administrator from Orthopedics- Pediatrics Brian Luben
Jason Pellman
Select Department Administrator from Music Therapy Seneca Block
Select Department Administrator from the Quality Service Center Susan Semrau
Please specify other UH Department/Division Administrator* must provide value
I am currently engaged in the following UH-based research project (indicate UH IRB number)* must provide value
Project 1 Principal Investigator* must provide value
Add another project? Yes
No
I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 2 Principal Investigator
Add another project Yes
No
I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 3 Principal Investigator
Add another project? Yes
No
I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 4 Principal Investigator
Please download, complete ALL sections and obtain signatures on the "UH Sponsor and Principal Investigator Certification" document. Please attach additional sheets if you are participating on more than 2 studies. Please upload the completed and signed "UH Sponsor Certification" document. Please attach additional sheets if you are participating on more than 2 studies.* must provide value
Please enter the name of the UH PI who has signed your UH Sponsor Certification Form.* must provide value
Voluntarily or involuntarily, has your academic appointment ever been or is it in the process of being denied, revoked, suspended, limited, restricted, diminished, canceled, relinquished, sanctioned, challenged, investigated, placed on probation, not renewed or disciplinary actions initiated, pending, or imposed?* must provide value
Yes
No
Voluntarily or involuntarily, has your renewal of membership in any professional organization ever been or is it in the process of being denied, revoked, suspended, limited, restricted, diminished, canceled, relinquished, sanctioned, challenged, investigated, placed on probation, not renewed or disciplinary actions initiated, pending, or imposed?* must provide value
Yes
No
Are you currently named as a defendant in any criminal case, excluding a minor traffic violation? (note that driving under the influence and similar offenses are not minor traffic violations) * must provide value
Yes
No
Have you ever been convicted of any felony or misdemeanor, whether federal, state, or local, excluding minor traffic violations? (note that driving under the influence and similar offenses are not minor traffic violations)* must provide value
Yes
No
Have you ever been excluded from participating in Medicare, Medicaid, or any similar federal or state health care program, or been subjected to any sanction, suspension, or limitation?* must provide value
Yes
No
Do you now or have you ever had any history of alcohol, drug or other chemical dependence? * must provide value
Yes
No
Have you undergone any inpatient or outpatient treatment for alcohol, drug or other chemical dependence?* must provide value
Yes
No
Do you have any physical or mental condition which could affect your ability to exercise the academic and scientific privileges requested or would require an accommodation in order for you to exercise the privileges requested safely and competently? * must provide value
Yes
No
If your answer to any of the above questions was "yes", please provide a detailed explanation.
Please enter your CREC Certification expiration date below. * must provide value
Today M-D-Y
Please download the "AUTHORIZATION AND RESEASE FROM LIABILITY" form. Please upload the completed AUTHORIZATION AND RELEASE FROM LIABILITY form. * must provide value
Please download the "UH Electronic Systems Agreement" document. Please upload the completed UH Electronic Systems Agreement document.* must provide value
*** Page 2 & 8 and must be completed and uploaded.
HIDDEN ON APP: For research personnel who DO NOT hold a valid clinical license (e.g. M.D., D.O., R.N.) or corresponding training certificate in the State of Ohio please select "YES".* must provide value
Yes
No
Do you hold a valid clinical license (e.g. M.D., D.O., R.N.) or corresponding training certificate in the State of Ohio?* must provide value
I hold a valid clinical license in the State of Ohio.
I do not hold a valid clinical license in the State of Ohio.
Please upload your State of Ohio Clinical License here. * must provide value
If Applicable: Please download the form: Rules for Non-Licensed Researchers in a Clinical Setting Please upload the completed form: Rules for Non-Licensed Researchers in a Clinical Setting* must provide value
Effective September 1, 2017, the University Hospitals Clinical Research Center (UHCRC) will institute a processing fee for Research Credentialing applications. Case Medical Students are exempt from this fee. PAYMENT OPTION 1- CASH, CREDIT CARD OR CHECK PAYMENT OPTION 2- GENERAL LEDGER ACCOUNT, PTAEO or CWRU SPEEDTYPE SELECT PAYMENT OPTION: * must provide value
OPTION 1- I have completed the Payment Reference Form and the UH Cashier's Office has processed my payment. I will upload my receipt below.
OPTION 2- I have emailed the Department Payment Form to UHCRCGrantsAccounting@UHhospitals.org and received a confirmation of receipt email. I will enter the date of the confirmation email below.
NOTE: This application is interactive based on your selection. After you select the payment option, documentation will be requested.
Please upload your receipt from the UH Cashier's Office here. * must provide value
Please enter the date of the Confirmation of Receipt email from UHCRC Grants Accounting.* must provide value
By clicking 'Yes' below you are certifying that you have read, understand and agree to abide by the following requirements:* must provide value
Yes
No
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