This form takes approximately 15 minutes to complete. Please note that any updates or changes made to this form after you have presented to the Future Research Topics (FRT) work group may require another FRT presentation. Immediately contact Patty Maloney at pam199@pitt.edu if there are changes.
Principal Investigator's First Name
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Principal Investigator's Last Name
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Principal Investigator's Degree(s)
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Principal Investigator's Title/Position
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Mailing Address
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State
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Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
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Principal Investigator's email:
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Principal Investigator's Phone Number
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Principal Investigator's Primary Institution
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What institution are you affiliated with?
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Would you like to specify another contact, e.g. a Co-I or Project Manager?
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Yes
No
First Name
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Last Name
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Title/Role
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Email address
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Phone
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Please indicate the date by which you will need your PaTH cost estimate.
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Please note that when planning with deadlines, a minimum of 40 business days are required to prepare a PaTH budget.
What is the full title of this project?
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What is the acronym/short title for this project?
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What type of study is being proposed?
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Retrospective Observational Prospective Observational Prospective Interventional - Randomized at Patient Level Prospective Interventional - Randomized at Site Level Pragmatic Clinical Trial Other
You selected "Other" for Study Type. Please specify:
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What is the study topic (check all that apply):
Behavioral Health
Cardiovascular Disease
Health Disparities
Healthcare Delivery/Utilization
Gastroenterology
LGBT Health
Mood Disorders
Muscular and Skeletal Disorders
Obesity/Diabetes
Oral Health
Pediatrics
Pulmonary/Respiratory Diseases
Sleep Disorders
Other
Describe "other" study type:
What are the aims of this project?
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Background/Significance
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What institutions do you want to participate in your project?
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Johns Hopkins University/Johns Hopkins Health System and Johns Hopkins Health Care
Geisinger Health System
Penn State Hershey
Temple University Lewis Katz School of Medicine/Temple Health
University of Pittsburgh/UPMC and UPMC Health Plan
Ohio State University
The University of Michigan
Other
Do you need PaTH to assist you with finding site PI(s)?
* must provide value
Yes
No
You must have a site PI identified at each PaTH site. Some investigators have someone they would like to work with, if you do not, we are happy to assist you in locating an investigator.
If other, please indicate institution:
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What is the length (in years) of this study?
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Anticipated start date of study:
* must provide value
Today M-D-Y
Anticipated end date of study:
* must provide value
Today M-D-Y
Will your queries be for individual or aggregate level data (counts)?
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Will you be requesting UPMC Health Plan data?
Yes
No
Please note that Health Plan data requires approval from the Health Plan, which meets once a month to review such requests.
Yes
No
Will you be doing participant recruitment for your study?
Yes
No
Would you like PaTH staff to assist with study recruitment efforts? (For example, send e-mails to participants)
Please note, not all data are complete. Please refer to attached Data Completeness Document. DATA PULL REQUEST INFORMATION
Research Question:
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Primary Outcome
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Secondary Outcome
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PART A - STUDY COHORT DESCRIPTION
Describe the inclusion and exclusion criteria for the patient cohort you wish to study.
PART B - FURTHER COHORT DESCRIPTION
You may wish to have your study cohort further described by certain variables of interest. Describe those variables here and provide table shell with how you want the query results to appear.
Make sure to include a list of ALL procedure or diagnosis codes, medications, or labs that will need to be used in the data pull.
PART B - FURTHER COHORT DESCRIPTION - TABLE SHELL
PART C - ADDITIONAL INFORMATION
What date do you need the prep-to-research data?
* must provide value
Today M-D-Y
Will you be requesting data (beyond prep-to-research data) from the PaTH Network as part of this study?
* must provide value
Yes
No
How many data pulls are you requesting?
* must provide value
*Please note, not all data fields within each table are complete. Please refer to attached Data Completeness Document and indicate in the appropriate table comment area 1) the scope of data required (i.e., lab data: lab results for chemistry, liver panel) and/or 2) any issues you may have regarding data completeness for the respective table. Are demographics data being requested?
Yes
No
Are vitals data being requested?
Yes
No
Are medication orders data being requested?
Yes
No
Are dispensed medications data being requested?
Yes
No
Are visits/encounters data being requested?
Yes
No
Comments for Visits/Encounters Data
Are diagnoses data being requested?
Yes
No
Are problem list/conditions data being requested?
Yes
No
Are procedures data being requested?
Yes
No
Are lab data being requested?
Yes
No
Are death date data being requested?
Yes
No
Death data is vital status (e.g., alive vs. dead, NOT cause of death)
Are PRO data being requested?
Yes
No
Are HealthPlan data being requested?
Yes
No
Please note: Health Plan data may take up to one month to be approved
Yes
No
Are Medicare data being requested?
Yes
No
Quarterly Bi-Annual Annual Other
Frequency of Data Pulls - Other
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Our review committee (FRT) meets every Monday at 1:00 PM Eastern. Please indicate your availability to meet with the group (select all that apply).
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Next Monday (1 week)
The following Monday (2 weeks)
Monday the week after (3 weeks)
How long will you need to have access to your project?
E.g. all years of your project, or perhaps just the first one or two or the last one or two. * must provide value
Do you plan to run complicated analyses or more straightforward?
(We have two sizes of desktops) * must provide value
Complicated
Straightforward
How many people will you need to have concurrent access to the data?
(# of people that access it at one time; e.g. you can have 5 people access, but only 2 concurrent seats for access) * must provide value
Does your study need patient stakeholders?
* must provide value
Yes
No
Do you need assistance in finding a stakeholder?
Yes
No
PaTH can link investigators to patient stakeholders through the MyPaTH Story Booth project.
Are patient-reported outcomes being collected as part of this study?
* must provide value
Yes
No
Please indicate what instrument(s) you plan to use
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Would you like to sign up for the PaTH Newsletter?
Yes
No
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