PEDSnet Collaboration Request Form

PEDSnet Collaboration

Request Form

First and Last Name:*

Please enter your email address:*

Your institution type:*

Select

If you selected other, please provide your institution type:*

Name of institution:*

PI First and Last Name*

PI Credentials*

(e.g., MD, PhD)

PI Professional Title*

(e.g., Associate Professor of

Pediatrics)

Name of "other" institution

Please list names and institutions of your co-investigator team, if known.

Do you have a secondary contact?*

Yes

Please enter your additional contact's email address*

Have you discussed your research idea with a PEDSnet Site PI?*

Yes

If "None of the above" please provide the name of the PEDSnet contact you discussed your research idea with.*

Expected Output from PEDSnet (check all that apply)*

Evaluation of PEDSnet data available for use in a planned study (feasibility query)

Aggregate results of data analyses

Development of a computable phenotype (re-usable computerized search queries that detect specific clinical events or conditions using electronic health record data)

Identification of eligible participants to facilitate study recruitment

Linking existing dataset with PEDSnet data

Manual review of medical records

Other

If "Other", please describe the type of request*

Working title of research concept*

Please provide a brief lay description of your research question:*

Please describe in more detail how you envision utilizing PEDSnet data to answer your research question.*

Variables that investigators intend to extract from PEDSnet data.*

(e.g., health conditions, medications, procedures). For more information, please see https://pedsnet.org/data/data-domains/

Study Design*

Select

If "Other" study design, please describe.*

Have you already collaborated on your research proposal with a patient or parent volunteer or a member of any like committee? This could be a member of the PEDSnet Engagement Committee or a member of any committee at your institution that involves patients and families.*

Yes

If 'yes' please provide the full name of your patient or parent collaborator.*

As a Patient-Centered Outcomes Research Institute (PCORI) funded network, patient engagement is required in all PEDSnet research proposals. Does your proposal include an engagement plan/perspectives from patients and families?*

Yes

No, Request that the PEDSnet CC assign an engagement representative

Please summarize your engagement plan:*

Please indicate a funding source for your request.*

Applying for a grant or submitting an LOI

Have already secured funding

Industry

Other

Please specify funding source:*

Please further specify the sponsor:*

Please indicate the amount of funding available for PEDSnet work*

Number of Funding Years*

Anticipated start date*

Anticipated End Date*

Grant Funding Announcement

Please copy the funding announcement URL for your grant submission into the below field. If you do not have the URL you may indicate "NA" and upload a PDF version of the announcement at the end of this form.*

Notice of Award Date

LOI Submission Deadline (If Applicable)

If you have already developed a proposal and/or Letter of Intent, please upload below.

If you have a PDF version of a grant funding announcement, please upload below.

(Note: Multiple documents can be uploaded in the below field).

File Upload:

Drag and drop files here or

Is there anything else you would like share about your request?

How did you hear about us?*

Select

Send me a copy of my responses

Research Needs

Funding

Grant Funding Announcement