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)
High School Student Enrolled in the Educational Experience Program Application
*** NOTE: THIS APPLICATION IS INTERACTIVE BASED ON YOUR SELECTIONS. DO NOT SKIP THIS QUESTION. ***
Legal First Name
* must provide value
Legal Last Name
* must provide value
Last 4 digits of your Social Security Number
* must provide value
Date of birth
* must provide value
M-D-Y
Are you over 18?
* must provide value
Yes
No
MINOR STUDENT CONFIDENTIALITY ACKNOWLEDGEMENT I understand that by participating in an Experience, I may have access to or obtain confidential and/or legally protected information about University Hospitals Health System ("UH") patients, including protected health information ("PHI") (collectively, "Patient Information"). As such, I will not share Patient Information with anyone outside of the Experience, including my family and friends, under any circumstance. I understand that patient confidentiality is of such great importance that PHI is NEVER to be shared with anyone even if it is years after I participate in the Experience. I understand that this acknowledgement shall remain effective for the duration of my Experience at UH. By checking the box, I acknowledge that I understand the confidentiality requirements that I must follow in order to participate in an Experience.
* must provide value
I acknowledge that I understand the confidentiality requirements I must follow in order to participate in an Experience at UH.
I do not acknowledge and will not participate in an Experience at UH.
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 addressNote: If you are affiliated with an institution, the email address must be from that institution.
* must provide value
Home address (number/street, city, state, zip)
* must provide value
I am a member or a student of the following institutions (check all that apply):ATTENTION: If you are affiliated with MetroHealth or the VA, please contact us prior to submitting an application.
* must provide value
*If your institution is not listed above, please contact UHResearchCredentailing@UHhospitals.org before completing an applicaiton.
Institution, school, or hospital you are from
Please provide the name of the UH affiliated hospital
Current Position/Title held at each affiliated institution that you have selected above
* must provide value
Please upload a current copy your ID issued by the institution that you have selected above. Please do not upload in HEIC format. This is an Apple format that we cannot open and this will hold up your application. Please submit as a PDF or JPG file.
* must provide value
If you are a CWRU Medical Student, please add your expected graduation date
* 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
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
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
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
High School Student
I have completed the required Criminal Background Check. We can no longer accept background checks by any company other than Corporate Screening/FirstAdvantage .
Submit through https://apps.corporatescreening.com/VendorWorkforce/Home , obtain a copy, and upload here.
please use special promotional code: patientaccess
A valid email is REQUIRED. Have your credit card (Visa/MasterCard/American Express/Discover) information ready in order to process payment. Your credit card will be charged $23.25 for the service. Complete profile & e-sign forms as they appear. Click the "Submit" button at the end of the process and you're done! You will be provided with an electronic receipt and confirmation code at the time of completion. ***A background check must be completed before your application will be reviewed.
* must provide value
Yes
No
* Please refer to page 6 of the SOP for instructions on how to obtain a background check.
Upload Corporate Screening background check.
***PLEASE NOTE: 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. Please email UHResearchCredentialing@UHhospitals.org with any questions. ***
A background verification is required with the School of Medicine.
Visit https://case.edu/medicine/students/registrar/forms Click the "Student Letter Request Form" Select the Background Check Verification Letter" option. Login with your CWRU ID and password. Complete the form and select "Email" as the Delivery Method and have the letter emailed to UHResearchCredentialing@UHhospitals.org. If you have previously been UH Research Credentialed this step is not required.
* must provide value
*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 working 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 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 Connor Integrated Health Nutrition
UH Department of Medicine Division you are working 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 working 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
Select Department Administrator from Biology/Epidemiology and Biostatistics
* must provide value
Select Department Administrator from Bioethics
* must provide value
Select Department Administrator from the Case Comprehensive Cancer Center
* must provide value
Select Department Administrator from Dentistry
* must provide value
Select Department Administrator from the Department of Dermatology
* must provide value
Select Department Administrator from the Department of Emergency Medicine
* must provide value
Select Department Administrator from the Department of Family Medicine and Community Health
* must provide value
Select Department Administrator from the Department of Genetics
* must provide value
Select Department Administrator from the Department of Neurology
* must provide value
Select Department Administrator from the Department of Neurological Surgery
* must provide value
Select Department Administrator from Nursing
* must provide value
Select Department Administrator from the Department of Ophthalmology
* must provide value
Select Department Administrator from the Department of Orthopedics
* must provide value
Select Department Administrator from the Department of Otolaryngology/Head and Neck Surgery and ENT
* must provide value
Select Department Administrator from the Department of Pathology
* must provide value
Select Department Administrator from the Department of Plastic Surgery
* must provide value
Select Department Administrator from the Department of Psychiatry
* must provide value
Select Department Administrator from the Department of Radiation Oncology
* must provide value
Select Department Administrator from the Department of Radiology
* must provide value
Select Department Administrator from the Department of Reproductive Biology (Obstetrics and Gynecology)
* must provide value
Select Department Administrator from the Department of Surgery
* must provide value
Select Department Administrator from the Department of Pharmacy
Select Department Administrator from the Department of Urology
* must provide value
Select Department Administrator from the Department of Pediatrics
* must provide value
Select Department Administrator from the Department of Medicine
* must provide value
Select Department Administrator from the Department of Rehabilitation Services
Select Department Administrator from the Dahms Clinical Research Unit
Select Department Administrator from Orthopedics- Pediatrics
Select Department Administrator from Music Therapy
Select Department Administrator from the Quality Service Center
Please specify other UH Department/Division Administrator
* must provide value
I will be working on the following UH-based research project (indicate UH IRB number)
* must provide value
Project 1 Principal Investigator
* must provide value
Yes
No
I will be working on the following UH-based research project (indicate UH IRB number)
Project 2 Principal Investigator
Yes
No
I will be working on the following UH-based research project (indicate UH IRB number)
Project 3 Principal Investigator
Yes
No
I will be working on the following UH-based research project (indicate UH IRB number)
Project 4 Principal Investigator
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.Note: If you are a high school student, please work with your sponsor to ensure necessary accommodations are acquired.
Please enter your CREC Certification expiration date below. To obtain your CREC Certification you must complete CITI BASIC course in the protection of human subjects in research offers three training groups: Choose only one course: *Group 1 focuses on Biomedical research *Group 2 focuses on Social & Behavioral research *IRB Reference Resource is a compilation of both research perspectives For additional information on how to become CITI Certified please visit: http://case.edu/research/faculty-staff/education/crec/ If you have completed your CREC Certification through an institution other than CWRU please contact UHResearchCredentialing@UHhospitals.org to see if your credits transfer in to the CWRU CREC Program.
* must provide value
Today M-D-Y
HIPAA Training for Minor Students
High school students under the age of 18 are required to complete HIPAA training. Follow the below instructions to access the required training module. Reach out to ClinicalResearch@UHhospitals.org if you have trouble accessing UH's learning management system, GPS.
Ask your Sponsor/Department Administrator to submit a SailPoint request for GPS using your preferred email address. A new GPS account will be created for you. Ask your Sponsor/Department Administrator to assign you the GPS course entitled, "Clinical Research Orientation - HIPAA and PHI in Research" (You will not have the ability to search for the course) Click this link to be routed to GPS: https://uhhospitals.csod.com/samldefault.aspx Using your email address, log in under the, "Non-Employee Self Registration Users" section. Click on the course, "Clinical Research Orientation - HIPAA and PHI in Research" Upon completion, please email your course certificate to UHResearchCredentialing@UHhospitals.org and your Sponsor/Department Administrator. Click the "Yes" box below to attest to reading these instructions and performing the necessary actions to take HIPAA training.
* must provide value
Yes No
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 3 studies.*INCOMPLETE FORMS WILL NOT BE ACCEPTED. PLEASE ENSURE EACH SECTION IS COMPLETE.
Please upload the completed and signed "UH Sponsor Certification" document. Please attach additional sheets if you are participating on more than 3 studies.*INCOMPLETE FORMS WILL NOT BE ACCEPTED. PLEASE ENSURE EACH SECTION IS COMPLETE. INCLUDING THE "ROLES AND RESPONSIBILITIES" LINE.
* must provide value
Please enter the name of the UH PI who has signed your UH Sponsor Certification Form.
* must provide value
Please download the "AUTHORIZATION AND RESEASE FROM LIABILITY" form.
Please upload the completed AUTHORIZATION AND RELEASE FROM LIABILITY terms. * Authorization and Release from Liability Forms must have a current date upon submission of your application. Forms submitted with a date greater than 30 days prior to submission will not be accepted.
Please read through the AUTHORIZATION AND RELEASE FROM LIABILITY terms. * Authorization and Release from Liability Forms must have a current date upon submission of your application. Forms submitted with a date greater than 30 days prior to submission will not be accepted.
By signing, I acknowledge the terms of the Authorization and Release from Liability form.
* must provide value
Please download the "UH Electronic Systems Agreement" document.Page 2 & 8 and must be completed and uploaded. Many people miss initialing page 2 (in 3 places). If you do not do this, you application will not be processed.
Please upload the completed UH Electronic Systems Agreement document.
* must provide value
*** Page 2 & 8 and must be completed and uploaded.
Please download the "High School Student Waiver and Confidentiality Agreement" document.
Please upload the completed "High School Student Waiver and Confidentiality Agreement" document with your parent or guardian's signature.
By signing, I acknowledge the terms of the High School Student Waiver and Confidentiality Agreement.
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
There is no payment required for high school students. Please proceed to the Certifications portion of the application.
Fees for Research CredentialingCWRU Medical Students are exempt from the research credentialing fee. • Initial Applications: $150 • Renewal Applications: $100 Please note that this fee is non-refundable if you pay using an option other than the InstaMed payment portal. PLEASE SEE PAYMENT OPTIONS BELOW AND MAKE YOUR SELECTION. NOTE: This application is interactive based on your selection. After you select the payment option, documentation will be requested.
PAYMENT OPTION 1- CASH, CREDIT CARD OR CHECKPlease print the Payment Reference Form attachment below. This form will need to be completed and taken to the UH Cashier's Office with your payment. You must save the receipt from the UH Cashiers Office to upload on to your research credentialing application. Applications without receipts will not be processed and any lost receipts will not be replaced. Please note that this fee is non-refundable. For any questions regarding the Payment Reference Sheet, please contact UHresearchcredentialing@uhhospitals.org. The Cashier's Office is located in the Humphrey Building, first floor, room 1629, near Pre-Admission Testing. Hours: 9:00 a.m. - 4:00 p.m. Monday - Friday (closed 2-3 for lunch)
PAYMENT OPTION 1 - CREDIT/DEBIT CARD, GOOGLE PAY, APPLE PAY Navigate to https://pay.instamed.com/Form/PaymentPortal/Default?id=research.credentialing If you log in to the website in Google Chrome, you will have the option to pay with Google Pay. If you log in using Safari, Apple Pay will be an option. If you are the applicant submitting payment for UH Research Credentialing, you may leave the "Guarantor" sections blank. If you are someone paying on behalf of the applicant , you are considered the guarantor. Please complete guarantor information. If this is your first time going through the UH Research Credentialing process, select, "INITIAL APPLICATION 150 DOLLARS" as the application type. If you are submitting a renewal, select, "RENEWAL 100 DOLLARS" as the application type. Click, "PAY NOW" InstaMed may request you to create an account. If you'd rather not create an account, click, "Continue as Guest" at the bottom of the page to proceed. Click on the "Payment Amount" box and type in the required fee amount (Initial = $150, Renewal = $100) If using a credit/debit card, key in the required information in the designated fields. Click "Next" You will be routed to a "Review & Confirm" screen. Please review all information to assure accuracy and click, "CONFIRM." On the "Payment Summary" page, click, "SHARE RECEIPT" In the pop-up window, email the receipt to UHResearchCredentialing@UHhospitals.org and click "Send." PAYMENT OPTION 2 - GENERAL LEDGER ACCOUNT, PTAEO or CWRU SPEEDTYPE Please open the Department Payment Form attachment below. Complete the form and email to UHCRCGrantsAccounting@UHhospitals.org . Upon receipt you will receive an email Confirmation of Receipt of your Department Payment Form and UH Research Credentialing will be copied on the email confirmation. You must enter the date of the confirmation email you received from UHCRC Grants Accounting below. SELECT PAYMENT OPTION:
* must provide value
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.
Please enter the date you submitted payment via credit/debit, Apple Pay, or Google Pay.
* must provide value
Today M-D-Y
Please enter the date of the Confirmation of Receipt email from UHCRC Grants Accounting.
* must provide value
Today M-D-Y
By clicking 'Yes' below you are certifying that you have read, understand and agree to abide by the following requirements:
As part of being on a research team, I may or will have access to Protected Health Information (PHI) from patients of University Hospitals. I will only access the minimum necessary PHI to fulfil my role and responsibilities on the research team. I will only access PHI in this role in accordance with UH policies on human subject research. I will abide by UH polices to ensure the privacy and security of UH patient PHI. I will obtain a UH network ID and UH email account and will use it for all research related work and communication. No other email address may be used to conduct UH business or transmit UH confidential information or PHI. Any research data containing PHI will only be stored on a UH encrypted device. If another device (mobile) is required, then it must be encrypted and use must be approved in writing by the PI and a UH IT representative. I will not share research data containing PHI with any third party without prior approval from UH and a Business Associate Agreement or Data Use Agreement. I will ensure UH login information and passwords are kept secure and not shared. I will contact the UH Privacy Office (216-286-6362) for privacy questions or UH Helpdesk (216-844-3327) for any information security questions. I will conduct myself in a professional manner in my role as a member of a research team. * must provide value
Yes
No
Submit
Save & Return Later