Pediatric Research Consortium Study Form

Study Information:HELP

Date:

Name of study:

Primary investigator name:

Co-investigator name:

IRB approval:

Yes No

If yes, IRB#:

If no, date anticipated:

Study Funding:HELP

Source of funding:

Direct funding amount:

Indirect funding amount:

Total funding amount:

Duration of award:

Description of Study:HELP

Study objectives:
Study design:
If other, provide information on design:
Study outcome:
What is the time commitment to the family/patient? (i.e. number of visits, length of each visit)
What resources are available to the patient/family after the study is over?

Study Participants Profile:HELP

Sample size of patients needed?
Preferred Study Site(s):
Primary Care Center(s):
Kids First Practice(s):
Timeline:
Is the anticipated study start date known?	Yes No
Please please enter the anticipated start date:
Is the anticipated study end date known?	Yes No
Please enter the anticipated study end date:
Are patients reimbursed for their time and effort?	Yes No
Please list and describe all patient reimbursement methods(i.e. gift cards, stipend, etc.):
Are there benefits to the patient (i.e. diagnostic testing at no cost, equipment, expedited appointment, etc.)?	Yes No
Please list and describe all patient benefits:

Practice Profile:HELP

What do physicians/nurse practitioners need to do?
What do nurses need to do?
What does the clerical staff need to do?
Will there be any space required? (i.e. storage for materials, exam room for interviewing, etc)?	Yes No
Please list and describe all space requirements:
Have you identified a primary care provider that is interested in becoming a "champion" or an associated clinical investigator for the project?	Yes No
If yes, please list contact information:
During the study period … Is patient care improved? (i.e. directly provides services or improves the delivery of care):	Yes No
If yes, please describe:
Are there benefits to the provider/practice?	Yes No
If yes, please describe:

Submit Study Form: