Research Credentialing Application

Returning?

A A A

Please do NOT complete an application if you are a UH employee.

IMPORTANT NOTE:

There is a non-refundable processing fee for Research Credentialing applications. Case Medical Students and high school students participating in the Educational Experience program are exempt from this fee.

• Initial Applications: $150
• Renewal Applications: $100

______________________________________________________

Your application will not be approved until all supporting documentation is received and completed.

All required supporting documentation should be uploaded into this application.

Paper copies will NOT be accepted.

Questions? Please send all questions to UHResearchCredentialing@UHhospitals.org.

-------------------------------------------------------------------------------

NOTE: If using the 'Save and Return Later' feature, you MUST retain the validation code provided in order to access your application. If you do not have your validation code you WILL NOT be able to access your current application and will need to start over.

--------------------------------------------------------------------------------

Application Start Date

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

reset

Legal First Name

* must provide value

Legal Last Name

* must provide value

Middle Name

What name do you go by?

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

reset

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.

reset

Gender assigned at birth

* must provide value

Male Female

reset

Gender identity

Pronouns

She/Her

He/Him

They/Them

Other

Indicate your pronouns

City, State, Country of Birth

* must provide value

Citizenship

* must provide value

United States Other

reset

If not a United States citizen, what is your permanent resident or visa status at the present time?

Submit a current copy of your permanent resident card or a current copy of your visa and employment authorization card.

Upload file

Email address
Note: 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

Expand

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

Case Western Reserve University

Ursuline College

UH Affiliated Hospitals ( including Southwest General, Lake Health, & Firelands Regional Medical Center)

Kent State Nursing Students

Cleveland State Nursing Students

Other *

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

Expand

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

Upload file

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

reset

By whom?

Describe your relationship

Expand

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

reset

By whom?

Describe your relationship

Name of your Employer -OR- Educational Institution

* must provide value

Please enter your Department, Division or School.
(Ex. Frances Payne Bolton School of Nursing, School of Dental Medicine, Department of Nutrition, ect.)

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

reset

I have completed the required Criminal Background Check from Corporate Screening. Please attach copy.

We can no longer accept background checks by any company other than Corporate Screening.

Submit through www.CorporateScreening.com, obtain a copy, and upload here.

***A background check must be completed before your application will be reviewed.

* must provide value

Yes

reset

Upload Corporate Screening background check.

Upload file

***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. ***

Upload file

A background verification is required with the School of Medicine.

If this is your FIRST research credentialing application you must:

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

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.

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

reset

UH Department you are working with:

* must provide value

UH Department of Medicine Division you are working with:

* must provide value

UH Department of Pediatric Division you are working with:

* must provide value

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

Select Department Administrator from Bioethics

* must provide value

Barb Daly

Select Department Administrator from the Case Comprehensive Cancer Center

* must provide value

Josephine Chan

Lauren Allyn

Select Department Administrator from Dentistry

* must provide value

Erin Rose Glending

Katriina Floderus

Select Department Administrator from the Department of Dermatology

* must provide value

Kymberlyn Warner

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

Amy Jamieson-Petonic

Select Department Administrator from the Department of Genetics

* must provide value

Julia Jackson

Select Department Administrator from the Department of Neurology

* must provide value

David Haney

Select Department Administrator from the Department of Neurological Surgery

* must provide value

Clara Knebusch

Select Department Administrator from Nursing

* must provide value

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

Hannah Conochan

Select Department Administrator from the Department of Orthopedics

* must provide value

Kerwin Samson

Select Department Administrator from the Department of Otolaryngology/Head and Neck Surgery and ENT

* must provide value

Lakeeta Shaw

Meghna Khare Nayate

Select Department Administrator from the Department of Pathology

* must provide value

Anne Windau

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

Carla Conroy

Select Department Administrator from the Department of Radiation Oncology

* must provide value

Lauren Allyn

Select Department Administrator from the Department of Radiology

* must provide value

Victoria Uram

Select Department Administrator from the Department of Reproductive Biology (Obstetrics and Gynecology)

* must provide value

Corinthia "Kink" Brauer

Select Department Administrator from the Department of Surgery
For Peds Surgery go to Peds section and select Morgan Pyzoha

* must provide value

Lisa DiNardo

Select Department Administrator from the Department of Pharmacy

Ronald Cowan

Select Department Administrator from the Department of Urology

* must provide value

Ellen Divoky

Select Department Administrator from the Department of Pediatrics

* must provide value

Sandra Costello

Jason Pellman

Rebecca Marie Baas

Alicia Trybus

Erin Figueira

Heather Richards

Sushma Narra

Andrea Kovach

Ryan Jastromb

Kejda Relari

Kristin Leuchtag

Morgan Pyzoha

Sherae Campbell

Mike Eiermann

Natalia Lerner & Aska Dix

Colleen Andrews

Christy Rybak

Joseph Fiorello

Select Department Administrator from the Department of Medicine

* must provide value

Steve Myers

Stacey Mazzurco

Josephine Chan

Richard Sukeena

Jill Barnholtz-Sloan

Jane Baum

Shawn Smith

Rebecca Kahl

Joe Stuczynski

Sara Rahmani

Heather Lohr

Courtney Byrne

Paul Dhillon

Lauren Allyn

Amanda Davies

Marina Miklas

Neena Newton

Patty Robertson-Horwedel

Julie Pasternak

Olubukunola Dwyer

Christy Rybak

Erica Chuhay

Select Department Administrator from the Department of Rehabilitation Services

Karen Bitzer

Select Department Administrator from the Dahms Clinical Research Unit

Noreen Roman

Select Department Administrator from Orthopedics- Pediatrics

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 will be working on the following UH-based research project (indicate UH IRB number)
Project 1

* must provide value

Project 1 Principal Investigator

* must provide value

Add another project?

Yes

reset

I will be working on the following UH-based research project (indicate UH IRB number)
Project 2

Project 2 Principal Investigator

Add another project

Yes

reset

I will be working on the following UH-based research project (indicate UH IRB number)
Project 3

Project 3 Principal Investigator

Add another project?

Yes

reset

I will be working on the following UH-based research project (indicate UH IRB number)
Project 4

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

reset

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

reset

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

reset

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

reset

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

reset

Do you now or have you ever had any history of alcohol, drug or other chemical dependence?

* must provide value

Yes

reset

Have you undergone any inpatient or outpatient treatment for alcohol, drug or other chemical dependence?

* must provide value

Yes

reset

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

reset

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.

Expand

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

***Most UH researchers take Group 1 or 2.

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

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

reset

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.

Attachment:UH Sponsor Certification Form_Revised 11.2023.pdf

Please upload the completed and signed "UH Sponsor Certification" document. Please attach additional sheets if you are participating on more than 3 studies.

This form MUST be signed by the appropriate UH Sponsor and PI. Forms missing signatures or information will not be processed.

*INCOMPLETE FORMS WILL NOT BE ACCEPTED. PLEASE ENSURE EACH SECTION IS COMPLETE. INCLUDING THE "ROLES AND RESPONSIBILITIES" LINE.

* must provide value

Upload file

Please enter the name of the UH SPONSOR who has signed your UH Sponsor Certification Form.

* must provide value

Please enter the name of the UH PI who has signed your UH Sponsor Certification Form.

* must provide value

Please enter the name of the UH CHAIRMAN of the department in which your research will be associated with.

*We MUST have this information to process your application.

Please download the "AUTHORIZATION AND RESEASE FROM LIABILITY" form.

Instructions: review, complete form and upload

Attachment:Authorization & Release from Liability.pdf

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.

Upload file

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

Add signature

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.

Attachment:UH Electronic Systems Agreement United(363700_2).pdf

Please upload the completed UH Electronic Systems Agreement document.

* must provide value

Upload file

Please download the "High School Student Waiver and Confidentiality Agreement" document.

Attachment:High Schedule Educational Experience Waiver and Confidentiality Agreement.pdf

Please upload the completed "High School Student Waiver and Confidentiality Agreement" document with your parent or guardian's signature.

Upload file

By signing, I acknowledge the terms of the High School Student Waiver and Confidentiality Agreement.

Add signature

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".

For research personnel who hold a valid clinical license (e.g. M.D., D.O., R.N.) or corresponding training certificate in the State of Ohio please select "NO".

* must provide value

Yes

reset

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.

reset

Please upload your State of Ohio Clinical License here.

* must provide value

Upload file

If Applicable: Please download the form: Rules for Non-Licensed Researchers in a Clinical Setting

Instructions: review, complete form and upload

Attachment:RULES FOR NON.pdf

Please upload the completed form: Rules for Non-Licensed Researchers in a Clinical Setting

* must provide value

Upload file

There is no payment required for high school students. Please proceed to the Certifications portion of the application.

Fees for Research Credentialing

CWRU 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 CHECK

Please 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.

Cashier's Office
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)

Attachment:Payment Reference Form.pdf

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.

Attachment:Department Payment Form.pdf

SELECT PAYMENT OPTION:

* must provide value

OPTION 1- I have paid via credit/debit, Apple Pay, or Google Pay online and the receipt has been shared with UHResearchCredentialing@UHhospitals.org.

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.

Please upload your receipt from the UH Cashier's Office here.

Upload file

Please enter the date you submitted payment via credit/debit, Apple Pay, or Google Pay.

* must provide value

M-D-Y

Please enter the date of the Confirmation of Receipt email from UHCRC Grants Accounting.

* must provide value

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

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Research Credentialing Application

START HERE

Application Type, General Information,

Academic Affiliation and Employment

Background Check, Department Affiliation, and Institutional Review Board Information

Disclosure Information

Training, Agreements, and Forms

Payment Options and Instructions

PAYMENT OPTION 1 - CREDIT/DEBIT CARD, GOOGLE PAY, APPLE PAY

PAYMENT OPTION 2 - GENERAL LEDGER ACCOUNT, PTAEO or CWRU SPEEDTYPE

Certifications and Submission of Application

You have selected an option that triggers this survey to end right now.

Research Credentialing Application

*START HERE*

Application Type, General Information,

Academic Affiliation and Employment

Background Check, Department Affiliation, and Institutional Review Board Information

Disclosure Information

Training, Agreements, and Forms

Payment Options and Instructions

PAYMENT OPTION 1 - CREDIT/DEBIT CARD, GOOGLE PAY, APPLE PAY

PAYMENT OPTION 2 - GENERAL LEDGER ACCOUNT, PTAEO or CWRU SPEEDTYPE

Certifications and Submission of Application

You have selected an option that triggers this survey to end right now.

START HERE