Investigator Request Form for CTSI Services

To request a REDCap account for building and managing online surveys, data entry forms, and databases, please submit a separate request at: https://www.ctsiredcap.pitt.edu/redcap/surveys/?s=injPIG. You do not need a REDCap account to fill out the form below.

Please fill out the following form in order to request services provided by the Clinical and Translational Science Institute.

Depending on what service you are requesting, we may ask you to submit information related to IRB/regulatory approval (such as a PittPRO title and number), PI contact information, and/or project/grant information (such as a project description/abstract, grant number, etc.). It can be helpful to have this information on hand before you submit a request.

You may save this page and return later for any request you start but do not submit by selecting "Save & Return Later" at the bottom of this page. After hitting the "Save & Return Later" button, please ensure you enter an email address to have the link sent to you so you may return to your request at a later time. If you do not return to update or submit your request within 10 business days, it may be deleted from our system, and you will need to start a new request.

Note: Only faculty/clinicians, fellows, medical students, and residents (with a faculty mentor) are permitted to submit requests for statistical consultations, help with statistical analyses or analysis plans, data management support (e.g., setting up REDCap projects, etc.), and power/sample size calculations for their research. These services are not currently available for graduate or undergraduate student research (e.g., for research related to a dissertation, thesis, practicum/internship, or coursework). Please contact CTSI@pitt.edu for questions about eligibility or alternative statistical resources for students.

If you have any questions about this form or available services, please contact ctsi@pitt.edu.

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Your First Name:

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Your Last Name:

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Your Email Address:

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Requestor Full Name:

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Which best describes your role?

Faculty and/or Clinician

Graduate Student

Fellow

Medical Student

Post-Doctoral Researcher

Resident

Staff

Undergraduate Student

Other role, please specify

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What is your primary affiliation?

University of Pittsburgh/UPMC

Another University, please specify

External Industry/Company, please specify

Non-Profit Organization, please specify

Other Affiliation, please specify

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What is your (primary) Pitt School or UPMC affiliation?

School of Arts & Sciences Department

Arts & Sciences: Other department, please specify:

School of Computing & Information Department

School of Computing & Information: Other department, please specify:

School of Medicine Department

School of Medicine: Other department, please specify:

Cardiothoracic Surgery Division

Cardiothoracic Surgery: Other division, please specify:

Medicine Division

Medicine: Other division, please specify:

Obstetrics, Gynecology and Reproductive Sciences Division

Obstetrics, Gynecology and Reproductive Sciences: Other division, please specify:

Pathology Division

Pathology: Other division, please specify:

Pediatrics Division

Pediatrics: Other division, please specify:

Radiology Division

Radiology: Other division, please specify:

Surgery Division

Surgery: Other division, please specify:

Engineering Department

Swanson School of Engineering: Other department, please specify:

Public Health Department

School of Public Health: Other department, please specify:

School of Education Department

School of Education: Other department, please specify:

School of Nursing Department

School of Nursing: Other department, please specify:

School of Pharmacy Department

School of Pharmacy: Other department, please specify:

School of Dental Medicine Department:

School of Dental Medicine: Other department, please specify:

School of Health & Rehabilitation Sciences Department

School of Health & Rehabilitation Sciences: Other department, please specify:

UPMC-Affiliated Only (no Pitt appointment), please specify department:

Other Pitt School/Office, please specify:

Are you submitting a request for services for a specific project or grant (currently funded or in the planning/application phase)?

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Yes

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What is the status of the study, project, or grant application associated with this request for CTSI services?

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Project/study/grant is in the early planning/application phase (i.e., not yet funded)

Project/study/grant has received a notice of award, but no research activities have started

Study-related research activities (e.g., recruitment/enrollment, data collection, data analysis, etc.) are ongoing

All study-related research activities are completed

N/A - my request is not specific to any project/study/grant

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If your request involves help with analyzing data, creating statistical analysis plans, and/or sample size or power calculations, it must be associated with a project, study, or grant to receive these services. If ANY of these are true, please select a different option above before proceeding.

What is the title of the project you're submitting a request for?

Please use the full project or grant title, not an abbreviation.

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If applicable, please enter any acronyms, abbreviations, or short titles you are using for your project/study title.

If available, please enter the grant number for your project.

What is your primary role on this project?

Primary Investigator/Program Director

Co-Primary Investigator

Co-Investigator

Research/Project Coordinator

Research/Lab Technician

Other Research Staff

Graduate Student

Undergraduate Student

Post Doctoral Researcher

Budget Administrator

Other, please specify:

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Primary Investigator (PI) First Name:

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Primary Investigator (PI) Last Name:

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PI Full Name:

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Primary Investigator (PI) Email:

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What is the Principal Investigator's primary affiliation?

University of Pittsburgh/UPMC

Another University, please specify

External Industry/Company, please specify

Non-Profit Organization, please specify

Other Affiliation, please specify

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What is your (primary) Pitt School or UPMC affiliation?

School of Arts & Sciences Department

Arts & Sciences: Other department, please specify:

School of Computing & Information Department

School of Computing & Information: Other department, please specify:

School of Medicine Department

School of Medicine: Other department, please specify:

Cardiothoracic Surgery Division

Cardiothoracic Surgery: Other division, please specify:

Medicine Division

Medicine: Other division, please specify:

Obstetrics, Gynecology and Reproductive Sciences Division

Obstetrics, Gynecology and Reproductive Sciences: Other division, please specify:

Pathology Division

Pathology: Other division, please specify:

Pediatrics Division

Pediatrics: Other division, please specify:

Radiology Division

Radiology: Other division, please specify:

Surgery Division

Surgery: Other division, please specify:

Engineering Department

Swanson School of Engineering: Other department, please specify:

Public Health Department

School of Public Health: Other department, please specify:

School of Education Department

School of Education: Other department, please specify:

School of Nursing Department

School of Nursing: Other department, please specify:

School of Pharmacy Department

School of Pharmacy: Other department, please specify:

School of Dental Medicine Department:

School of Dental Medicine: Other department, please specify:

School of Health & Rehabilitation Sciences Department

School of Health & Rehabilitation Sciences: Other department, please specify:

UPMC-Affiliated Only (no Pitt appointment), please specify department:

Other Pitt School/Office, please specify:

What type of regulatory approval does this project require/have? Check all that apply.

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IRB

IACUC

IND

IDE

NDA

BLA

Patent

I don't know

Not applicable/Project is not research

Is this project a Quality Improvement/Quality Assurance project?

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Yes

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What is the regulatory status of this project?

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Application(s) not started yet

At least one application started, but none submitted

At least one application submitted

At least one application approved

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PittPRO/IRB Protocol Title:
PittPRO/External IRB Number:

IND Number:

IDE Number:

Has CTSI provided any assistance on this project before?

Yes

I don't know

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Which service(s) would you like to discuss with a CTSI service provider at this time? You may select all that apply.

If you do not immediately need a listed service, please do not check it. Please submit another request at the time that service is needed.

Note: For Health Record Research Request (R3) requests, please submit a separate request at http://rio.pitt.edu/services.

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Community Engagement Support

CTRC/CTRP/Research Network Support

Data Management (e.g., REDCap) Consultation

DSMB Requests/Cost Estimates

Grant Preparation: Statistical Analysis Plan, Sample Size/Power Calculations

Letter of Support for a Grant Application

Human-Centered Design Consultation/Training

Dissemination and Implementation Assistance (D&I tools, design, and/or methods)

Pitt+Me/Recruitment Support

Pitt+Me Discovery

Regulatory/IRB Protocol Support/Consent Development

Responsible Conduct of Research or Related Training Plans/Certification Letters

Statistical Consultation/Help Conducting Statistical Analyses

Other, please specify

Note: Statistical consultation and help with analysis, data management, analysis plans, or sample size/power calculations are available to faculty/clinicians, fellows, and medical students. Residents must have a faculty mentor for help with statistical services. For questions about whether you are eligible for these services or for help locating alternative statistical resources, please contact CTSI@pitt.edu.

Is this request directly related to a formal scholarly project?

Yes, Longitudinal Research Project (LRP)

Yes, Deans Summer Research Project (DSRP)

No, neither of these options

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CTSI is only able to provide support for medical student scholarly projects (LRP and DSRP) when requesting the following services:

Statistical Consultation/Help Conducting Statistical Analyses
Data Management (e.g., REDCap) Consultations
Grant Preparation: Statistical Analysis Plan, Sample Size/Power Calculations

Based on your responses, you are ineligible for these 3 types of services. Uncheck any and all of the 3 options bulleted above.

Contact ctsi@pitt.edu if you have any questions about eligibility for services or alternative statistical resources for students.

CTSI is unable to provide support for graduate or undergraduate student research (e.g., thesis, dissertation, practicum/internship, or coursework) for the following services:

Statistical Consultation/Help Conducting Statistical Analyses
Data Management (e.g., REDCap) Consultations
Grant Preparation: Statistical Analysis Plan, Sample Size/Power Calculations

You will need to uncheck any and all of these options above before you submit your request.

Contact ctsi@pitt.edu if you have any questions about eligibility for services or alternative statistical resources for students.

Residents are required to submit the name of their faculty mentor for assistance with BERD services (statistical analysis, study design, etc.). Please enter the name of your faculty mentor below:

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Which Pediatric PittNet services are you requesting? You can visit https://pedspittnet.pitt.edu/researchers/services for more information. Select all that apply.

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PittNet Research Staff Recruitment

Posting

Practive Improvement

Quality Improvement

Survey

Pediatric PittNet Request/Application Follow-Up Information

What type of funding source does this project have? Select all that apply.

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Federal Non-PHS Agency

Federal PHS Agency

Industry

Institutional

Other funding

Non-PHS Agency Code:
Non-PHS Grant Number:

PHS Activity Code (i.e. if your grant number is r01CA123456, enter r01):
PHS Agency Code (i.e. if your grant number is r01CA123456, Select CA):

Is this an OSPARS study?
Industrial Sponsor:
Is this a PI-initiated study?
Is this an Industry-initiated study?

Please list any benefits practices and/or participants can expect from participating in your study.

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Please enter the following information about your protocol:

Projected of Study Duration in Years:
Projected Enrollment Period of Study in Years:
Projected Number of Participants to enroll:
Number of expected enrolled participants with PittNet:
Duration of study per participant:
Number of visits per participant:
Earliest start date:
Number of potential participants expected to screen:

Pitt+Me Discovery Request Follow-Up Information

Pitt+Me Discovery Request Type

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Data request

Sample request

Other request

Please list any other collaborators, team members, or affiliated institutions for this project:

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Requests for Discovery require the submission of a project description and/or an abstract/aims. Would you like to upload a file or enter the project description in a text box to provide this information?

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File Upload

Textbox

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Please upload a project description/abstract/aims as a PDF or Word document (DO NOT SUBMIT IDENTIFIABLE DATASETS!):

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Upload file

Please provide a description/abstract/aims of your project in the space below:

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Is this project currently funded?

Yes

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Required Information for a Letter of Support for Grant Applications

Please confirm the name of the PI and their title in the space below. If there are multiple PIs for the grant application, please list all of them along with their titles:

* must provide value

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Please confirm that the grant/project title you entered earlier in this request form is the grant title you will use for the grant application:

______

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Yes, this is the title for the grant application

No, I would like to enter a new title:

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We need a copy of the funding opportunity announcement (FOA) to fulfill this request. Would you like to provide a link or upload a PDF?

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Provide a link (FOA number is also acceptable):

Upload a PDF:

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Is this letter for the resubmission of a previously reviewed application (e.g., NIH A1 application)?

Yes

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Please upload a copy of your Specific Aims page (not just the aims themselves) or equivalent if the application does not include a Specific Aims page. A working draft is fine for this request.

* must provide value

Upload file

When do you need a signed letter by?

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M-D-Y

Please check each service or resource that could support your research, depending on your focus. We can create the letter with just your Specific Aims draft, but this checklist may suggest new ways in which CTSI can support your research.

Our Research Facilitators can explain any service or resource in more detail and help provide details specific to your application (e.g., number of potentially eligible participants enrolled in Pitt+Me based on your study criteria).

Human subjects research:

Translational, in vivo, in vitro, and in silico research:

Resources to support research teams:

Resources to support training, faculty development, and/or center grant applications:

Human Subjects Research

Assistance with IRB, single IRB, & other regulatory requirements

Assistance with setting up & managing Data Safety & Monitoring Board/Plan

Statistical/bioinformatics help with power calculations, study design, data management plans, data sharing plans, data analysis

Single and multi-site clinical trial planning (sites, cohort discovery, collaborator discovery, regulatory approvals, documentation, oversight, training, clinical trialist network/mentoring, etc.)

REDCap data collection

eConsent support

TeleResearch support

Community-Stakeholder Engagement through referrals, Community Ambassadors, Community Engagement Studios, human-centered design exercises, Stakeholder Engagement Playbook, Community PARTners Research Ethics Training (certifies community member(s) to serve on IRB-approved protocols)

Recruitment assistance (Pitt+Me, social media)

Use of Clinical & Translational Research Center (inpatient/outpatient visits)

Use of Practice-Based Research Network

CTSI Discovery Biobank: enrollment, biospecimen collection, DNA extraction-storage, pharmacogenomics analysis, biobank data for secondary analyses

Research Data Warehouse for provisioning electronic health record and other data, integrating data from multiple sources (including data collected for research) in a secure data mart

Clinical Research Coordinator training, networking, continuing education, & diversity hiring opportunities

Pilot research funding (special populations, across the lifespan, social determinants of health, research dissemination, health inequity, etc.), bonus awards, and competitions (Pitt Innovation Challenge/PInCh, Pain Research Challenge)

Assistance selecting an implementation framework, conducting an implementation needs assessment, selecting implementation strategies and outcomes, evaluation tools, and other aspects of planning and conducting implementation projects and hybrid efficacy-implementation research

Assistance developing a dissemination plan

Assistance adapting CTSI infographic template to return study results to research participants and community

Participation in Implementation Lab implementation projects with operations partners (UPMC, UPMC Health Plan, Children's Community Pediatrics, VA Pittsburgh, Allegheny County Health Department)

[OPTIONAL] Please upload any relevant file or document that may help with this request (e.g., abstract, specific aims page, etc.).

DO NOT SUBMIT IDENTIFIABLE DATASETS!

Upload file

How did you hear about the services you're requesting today? Check all that apply.

Word of mouth (e.g., colleague, mentor, etc.)

CTSI/Pitt website

On-campus/virtual signage (e.g., posters, flyers, etc.)

CTSI presentation/tabling

CTSI-sponsored event

Referred by a CTSI staff/team member

Referral from another Pitt/UPMC office

Through previous experience using CTSI services

Other, please specify:

What can CTSI do to assist you at this time? Please provide a short (500 words or less) description of your request(s).

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Is there any additional information that we should know about this request for CTSI services?

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Whether you're Pitt staff, faculty, or student, part of a research team or just a member of the community, CTSI Updates is a great way to stay current on research processes, available resources, education and training seminars, funding or study opportunities and more!

Click here to sign up for CTSI Updates!

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