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Required format:

Research Recruitment & Community Outreach Strategy Consultation Request

Greetings from the Clinical Research Center. As part of our service offerings to you, we provide guidance on the most effective methods for meeting your study recruitment goals and for building lasting relationships with the populations you serve. The following questions will help us prepare to consult with you. Additional guidance on how to complete this survey is available, contact ClinicalResearch@UHhospitals.org.

Thank you!

Date

M-D-Y

How did you find out about the recruitment consultations?

UHhospitals/Clinical-Research

Feasibility Email

Referral from Recruitment Specialist

Research Education Email

Other

Velos Email

New Study Letter

Sparta Modification

Education Session/Orientation

Discover with UH

Referral

Other

Sparta IRB Number

Short Title:

* must provide value

Working project title:

* must provide value

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Brief description of project:

* must provide value

Expand

(Proposed) Project Funding Source:

Provide description of funding source (examples: name of UH internal department funding source, federal or foundation RFA title, federal institute, foundation name):

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Funding status:

* must provide value

Is there budgeted allocation for recruitment plan development?

* must provide value

Yes

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Please share the approximate budget amount allocated for recruitment services:

Projected/Actual funding date:

* must provide value

M-D-Y

Project implementation phase:

* must provide value

IRB approval date:

M-D-Y

Number of participants to be enrolled:

* must provide value

Proposed/Actual enrollment start date:

* must provide value

M-D-Y

Proposed enrollment end date:

* must provide value

M-D-Y

Enrollment as of today:

Number of screen failures:

Gender:

Female

Male

Other

Describe:

Eligibility age:

* must provide value

Do you need assistance targeting special populations?

* must provide value

Yes

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Special Populations are those in which disparities in health are defined as differences in health outcomes and their determinants between segments of the population, as influenced by social, demographic, environmental, and geographic attributes (Centers for Disease Control and Prevention, 2014). Determinants of health include age; sexual orientation; race and ethnicity; physical illness, mental illness, or disabilities; socioeconomic status; and geography of residence (rural or urban area as well as safety and access to health promoting facilities).

Special populations to target:

Geriatrics

Minority populations

Pediatrics

Underserved populations

Other

Special Populations please explain

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Describe targeted population:

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Potential recruitment sites:

* must provide value

UHCMC

Community hospital sites

Community physician office sites

Community

Other

Potential Recruitment Sites

Expand

Describe:

Expand

Proposed/IRB-approved recruitment methods:

* must provide value

Subjects from the practice of a study investigator

Subjects referred or recruited from other physicians' practices

Subject recruitment by advertisement, flyer(s), web pages, etc.

Subjects identified from electronic medical record or database outside the investigator's division or group (e.g., TriNetX, Research IT, etc.)

Subjects studies or recruited from primary or secondary schools

Physician to physician recruitment

Email (IRB templates required)

Letter (IRB templates required)

Phone call (requiring phone script. Note: Phone calls can only be made after the study has been introduced in person, by letter, or email. Cold calling is not generally permissible.)

Advertisement (e.g., poster, brochure, flyers, radio, TV, etc.)

Social Media or online resources (FaceBook, Twitter, Instagram, LinkedIn, patient advocacy group, online clinical trials finder, ResearchMatch)

Approach potential subject during a clinical visit

UH CRC recruitment resources (i.e. recruitment hub, community event, etc.)

Other

UH Clinical Study and Trial Finder

Describe:

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Is the study team planning to use E-consent?

* must provide value

Yes

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Upload proposed recruitment plan

Upload file

Upload additional materials:

Upload file

Upload additional materials:

Upload file

Name:

* must provide value

Role:

Describe your role on this project:

Email address:

Telephone number:

Principal Investigator

* must provide value

Primary affiliation:

Department:

Division:

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