Research Credentialing Application

Please select one of the following:

First Name

Last Name

Middle Name

Other name by which you have been known

Last 4 digits of your Social Security Number

Date of birth

Gender

City, State, Country of Birth

Citizenship

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.

Email address

Home address (number/street, city, state, zip)

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.

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

If you are a CWRU Medical Student please add your expected graduation date

Do you hold a position as an administrator, director, or trustee of any hospital, health care system and/or health care entity?

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?

By whom?

Describe your relationship

Name of your Employer -OR- Educational Institution

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

Office Address (number/street, city, state, zip)

Office phone

Office manager

Requested Appointment Category

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.

Upload Corporate Screening background check.

***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.

Please email UHResearchCredentialing@UHhospitals.org with any questions. ***

A background verification is required with the School of Medicine.

If this is your FIRST research credentialing application you must:
1. Visit https://case.edu/medicine/students/registrar/forms
2. Click the "Student Letter Request Form".
3. Select the Background Check Verification Letter" option.
4. Login with your CWRU ID and password.
5. 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.

UH Department of Medicine Division you are associated with:

UH Department of Pediatric Division you are associated with:

Select Department Administrator from the Department of Anesthesiology and Perioperative Medicine

Select Department Administrator from Bioethics

Select Department Administrator from the Department of Emergency Medicine

Select Department Administrator from the Department of Plastic Surgery

Select Department Administrator from the Department of Psychiatry

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

Select Department Administrator from the Department of Pharmacy

Select Department Administrator from the Department of Rehabilitation Services

Select Department Administrator from Music Therapy

Select Department Administrator from the Quality Service Center

Please specify other UH Department/Division Administrator

I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 1

Project 1 Principal Investigator

Add another project?

I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 2

Project 2 Principal Investigator

Add another project

I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 3

Project 3 Principal Investigator

Add another project?

I am currently engaged in the following UH-based research project (indicate UH IRB number)
Project 4

Project 4 Principal Investigator

Please upload the completed and signed "UH Sponsor Certification" document. Please attach additional sheets if you are participating on more than 2 studies.

This form MUST be signed by the appropriate UH Sponsor and PI. We must have the Department Chairman's printed name. Forms missing signatures or information will not be processed.

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

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

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

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.

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?

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?

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)

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)

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?

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

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

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?

If your answer to any of the above questions was "yes", please provide a detailed explanation.

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.

Please upload the completed AUTHORIZATION AND RELEASE FROM LIABILITY form.

* 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 upload the completed UH Electronic Systems Agreement document.

Do you hold a valid clinical license (e.g. M.D., D.O., R.N.) or corresponding training certificate in the State of Ohio?

Please upload your State of Ohio Clinical License here.

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

SELECT PAYMENT OPTION:

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

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

By clicking 'Yes' below you are certifying that you have read, understand and agree to abide by the following requirements:

1. You are or will be a member of a research team conducting a study at University Hospitals;
2. As part of being on a research team you may or will have access to Protected Health Information (PHI) from patients of University Hospitals;
3. The PHI you will have access to is the minimum necessary to fulfil your roles and responsibilities on the research team;
4. Any PHI you will have access to in this role will be in accordance with UH policies on human subject research;
5. You will abide by UH polices to ensure the privacy and security of UH patient PHI;
6. You 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;
7. Research data containing PHI will not be shared with any third party without prior approval from UH and a Business Associate or Data Use Agreement;
8. You will ensure UH login information and passwords are kept secure and not shared;
9. You have reviewed the Use of Patient Records for Research FAQ Guide;
10. You will contact the UH Privacy Office (216-286-6362) for privacy questions or UH Helpdesk (216-844-3327) for any information security questions.