Today M-D-Y
Requestor First Name
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Requestor Last Name
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Requestor Email
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PI First Name
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PI Last Name
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PI Email Address
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Study Department
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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
Study Coordinator's Email
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Regulatory Coordinator's Email
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Study/Protocol Title
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Short Study Title
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Protocol Origin
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Investigator Initiated Industry Sponsor Federal (NIH, etc.) Other
Study Phase
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N/A
Phase 1
Phase 2
Phase 3
Phase 4
Post-Approval
Type of Study (select all that apply)
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Drug / Product / Supplement
Device
Surgical Procedure
Software
Biologic
Rollover/Long-Term Follow-Up (study extension)
Other (describe below)
IND/IDE Holder
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Investigator (single site)
Investigator (multi-site)
Sponsor
CTSC Department/Internal Federal - NIH Federal - DOD Federal - DOE Federal - NSF Federal - Other Foundation/Association Industry State Government Other
Other Funding Source
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If NIH, provide award type and PI name
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Foundation Name/Sponsor Name
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Study Institution
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UH
CWRU
Is this an oncology study being conducted through Seidman CTU?
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No Yes
Study Classification- Please identify if your protocol is recruiting any of the following:
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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:
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Anticipated Accrual Across ALL Study Sites
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Anticipated Accrual at Local Site
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Proposed UH Recruitment/Accrual START DATE:
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Today M-D-Y
Estimated UH Recruitment/Accrual STOP DATE:
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Today M-D-Y
ENROLLMENT:
To obtain the number of eligible subjects for study participation, a query of the electronic medical record (EMR) BY THE CRC will be conducted through TriNetX Software based on the information provided below.
For best results, please:
1) Complete Primary Diagnosis and Age fields, as these are MANDATORY for entry into TriNetX. ICD-10 codes are preferred if available.
2) Copy and paste the inclusion and exclusion criteria directly from the most recent protocol to help narrow the focus and range of the query through TriNetX. Please be sure characters or symbols are entered correctly.
3) Please avoid using Inclusion Criteria of "must sign informed consent". Start Date for Query
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Today M-D-Y
Stop Date for Query
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Today M-D-Y
Age Minimum
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Age Maximum
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Primary Diagnosis (ICD10)
For COVID-19 please select: "U07.1"
You can list all other codes in the inclusion free text boxes if you cannot find the exact code you need.
This field is pulled from an ICD dictionary and may be missing some newer or very specific codes.
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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
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Inclusion Criteria #2
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Inclusion Criteria #3
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Would you like to include more inclusion criteria?
Yes No
Please list additional inclusion criteria as a numbered list:
Exclusion Criteria #1
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Exclusion Criteria #2
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Exclusion Criteria #3
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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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