Date of Submission Today M-D-Y
Requestor First Name* must provide value
Requestor Last Name* must provide value
Requestor Email* must provide value
PI First Name* must provide value
PI Last Name* must provide value
PI Email Address* must provide value
Study Department* must provide value
Anesthesiology Cancer Center Dermatology Emergency Medicine Family Medicine Genetics Geriatrics Medicine - Cardiology Medicine - Endocrinology Medicine - Gastroenterology Medicine - Hematology/Oncology Medicine - Hypertension Medicine - Infectious Disease Medicine - Medicine Medicine - Nephrology Medicine - Pulmonary and Critical Care Medicine Medicine - Rheumatology Medicine - Sleep Neurology Neurological Surgery Nursing Obstetrics/Gynecology Ophthalmology Orthopedics Otolaryngology Pathology Pediatrics - Cardiology Pediatrics - Emergency Medicine Pediatrics - Gastroenterology Pediatrics - Hematology/Oncology Pediatrics - Infectious Disease Pediatrics - Nephrology Pediatrics - Neonatology Pediatrics - Neurology Pediatrics - Pediatrics Pediatrics - Pharmacology/Critical Care Pediatrics - Pulmonology Pediatrics - Psychiatry Pediatrics - Surgery Pharmacy Plastic Surgery Psychiatry Radiation Oncology Radiology Sports Medicine Surgery Urology School of Dentistry UH Clinical Research Center Other, please specify below
Other Department
Study Coordinator's Email* must provide value
Regulatory Coordinator's Email* must provide value
Study/Protocol Title* must provide value
Short Study Title* must provide value
Study Phase* must provide value
N/A
Phase 1
Phase 2
Phase 3
Phase 4
Post-Approval
Type of Study (select all that apply)* must provide value
Drug
Device
Surgical Procedure
Software
Biologic
Other (describe below)
Other
IND/IDE Holder* must provide value
Investigator (single site)
Investigator (multi-site)
Sponsor
Funding Source CTSC Department/Internal Federal - NIH Federal - DOD Federal - DOE Federal - NSF Federal - Other Foundation/Association Industry State Government Other
Other Funding Source* must provide value
If NIH, provide award type and PI name * must provide value
Foundation Name/Sponsor Name* must provide value
Study Institution* must provide value
UH
CWRU
Is this an oncology study being conducted through Seidman CTU?* must provide value
No Yes
Study Classification- Please identify if your protocol is recruiting any of the following:* must provide value
Rare Disease
Specific Genotype
Acute Illness
Recruiting Healthy Volunteers ONLY
Recruitment from Community Sites or Non-UH Sites
Eligibility criteria that is not available in the UH EMR systems and/or unable to be queried through TriNetX
N/A- None of the above apply to this protocol
Please explain:* must provide value
Anticipated Accrual Across ALL Study Sites* must provide value
Anticipated Accrual at Local Site* must provide value
Proposed UH Recruitment/Accrual START DATE:* must provide value
Today M-D-Y
Estimated UH Recruitment/Accrual STOP DATE:* must provide value
Today M-D-Y
ENROLLMENT: Start Date for Query* must provide value
Today M-D-Y
Stop Date for Query* must provide value
Today M-D-Y
Age Minimum* must provide value
Age Maximum (if none, enter 200)* must provide value
Primary Diagnosis (ICD10)* must provide value
Type to begin searching
Secondary Diagnosis (ICD10)
Type to begin searching
Additional Diagnosis (ICD9- Clinical Modification)
Type to begin searching
Additional Diagnosis (ICD10- Clinical Modification)
Type to begin searching
Optional: Procedure (ICD10 Procedure Coding System)
Type to begin searching
Inclusion Criteria #1* must provide value
Inclusion Criteria #2* must provide value
Inclusion Criteria #3* must provide value
Would you like to include more inclusion criteria? Yes No
Please list additional inclusion criteria as a numbered list:
Exclusion Criteria #1* must provide value
Exclusion Criteria #2* must provide value
Exclusion Criteria #3* must provide value
Would you like to include more exclusion criteria? Yes No
Please list additional exclusion criteria as a numbered list:
Please attach Protocol or Synopsis:
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