Clinical Epidemiology Center Request

Please take some time to respond to the following questions. In your meeting with a Clinical Epidemiology Coordinator, we will review your responses in detail.

Investigator name
Department / division
VA affiliation (include percent detail) / ___ / 8ths
WOC appointment?
- If “Yes”, are you on an IPA with the VA? / ____Yes ____ No
____Yes ____ No
External Affiliation (e.g., Washington University, Saint Louis University, etc.)
-If “Yes”, please list: / ____Yes ____ No
Resident status: Are you a medical resident? / ____Yes ____ No
Do you have a VA affiliated mentor?
-If “Yes”, who? / ____Yes ____ No
Is this research grant funded?
- If funded, is the source the VA?
-If funded, are you the PI on the grant? / ____Yes ____ No
____Yes ____ No
____Yes ____ No
Have you ever been the PI on a funded grant? / ____Yes ____ No
Phone
Alternate phone
Email
Alternate email
Address

Note about eligibility and CEC priority assignments:Investigators within the St. Louis VA Health Care System community, in general, are all able to access services from the CEC, but our mission is to support the work of junior investigators currently working for the VA. The CEC will use the above information to assign priority to your application, giving preference to applicants who meet the following criteria:

Have at least a 1/8th VA appointment
Have not been the PI of a funded grant previously
Have long term goals for their research, including seeking funding

What is your intended research topic or focus? Please provide basic descriptions of your current hypotheses and/or research questions.
Is your study IRB approved? If yes, please provide IRB protocol #
Do you currently have data for this project?
If yes, please specify what type of data (e.g., quantitative or qualitative), your plans and timeline for accessing data (e.g., data collection procedures, or, if secondary, data source and plan for procuring dataset). If you intend to request assistance from the CEC in assembling your dataset, please indicate that.
What is the primary purpose of your current study? Please circle (or highlight) all that apply.

Academic (papers, presentations, etc)
Pilot data for grant proposal
Quality Improvement study (please indicate if this has been determined by the IRB to be a QI study)
Other – please explain.

What specific needs are you requesting from the CEC? (Please note that we understand needs may be flexible; we will help determine your needs at the initial meeting with your coordinators).
Please specify an ideal time frame for meeting your request(s). (Example: On or before a specific date). Note: Every effort will be made to accommodate your request, although the CEC cannot guarantee your deadline will be met.
Do you have plans for subsequent research based on the results of this research? If so, do you plan to seek funding for this? If so, what grants would you apply for?
Are there any other notes about your study in terms of special procedures of which we should be aware?

Edited 10.02.14