Scholarly Activity - Initial Proposal

To proceed, you MUST have a signed faculty/department sponsor approval form.

Before completing this form, consider reviewing the scholarly activity planning sheets:

Case Report

Quality Improvement

Research Study

Last Name*

First Name*

Name of PI (if different than above)

Collaborators (if applicable)

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Other Collaborators:

Provide students, non-resident staff, or faculty names that do not appear on the above list.

Email*

Western Reserve Hospital staff members must use their employee email addresses. Medical students must use their school email addresses.

Employee Status*

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Residency Program*

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Program Year*

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Medical School*

Department*

Project Aim*

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Research Expo Declaration*

2025 Research EXPO: CLOSED

By checking this box, I declare my intent to participate in the 2026 WRH Research Expo.

Research Declaration Deadline: November 30th, 2025

Poster Deadline: January 31st, 2026*

*Residents must submit two peer-review affidavits with their poster.

Alert!*

Only the following scholarly activity categories will be judged at the Research EXPO: Research Study, Case Report/Series, and Quality Improvement

All other categories are exhibition only and will not be judged. By checking the box, you acknowledge receipt of this information.

Research Expo Attestation of Attendance*

I agree to attend the Research EXPO to present my research to the judging panel. February 2025

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Lecture/Grand Rounds/Teaching*

Did you complete a lecture, teaching, or case presentation (such as grand rounds) of at least 30 minutes duration?

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Conference Status:*

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Conference Details*

Please provide as many conference details as you can.

Publication Status:*

If your project is ongoing and you plan to pursue publication in the future, please select "pursuing publication."

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Publication Link:*

PMID:*

Coordinator Email*

Please include your coordinator's email address. They will be copied on all update requests.

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Project Status:*

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Scholarly Activity*

For teachings/lectures (30min+), comprehensive literature reviews, and reports of clinical techniques, please select "Other."

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Content*

Textbook Name*

Publisher

Documents Uploaded?*

Please upload the following documents above: Delegation Log, CITI Training, Other Required Training Logs, Protocol, CTA/Budget, IRB Approval Letter

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Protocol Title and Number*

Trial Sponsor*

CRO (if applicable)

Delegations/Role*

Site Activation Date*

Name of Outside (or Central) IRB*

Initial IRB Approval Date*

Description of Scholarly Activity*

Please include as much information as possible.

Detailed Description of Scholarly Activity*

Please provide as much information as possible. You MUST include the names of all outside institutions responsible for regulating this research.

Project Type*

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If other, please describe your study design

Have you completed a thorough review of the literature?*

REQUIRED for all projects.

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Summary of Literature Review*

Please include a few sentences about the background and rationale for your project.

Research Question*

A well-structured research question must identify the following elements: Population, Intervention, Comparison, and Outcome. For more information and examples, please review the PICO form provided by EBSCO.

Population*

Patient or population you intend to study.

Intervention*

Intervention or treatment you plan to use.

Comparison*

Comparison of one intervention to another.

Outcome*

The outcome you anticipate.

Primary Objectives*

Secondary Objectives (if applicable)

Required/Requested Resources*

Please outline all anticipated resources. This includes staff, equipment, funding, development tools, and data tools. If funding is required, please check the box below.

Funding Application Request

If your project requires funding (as outlined above), please select this box to receive a LECOM grant application.

Case Report Title*

Number of Subjects*

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Abstract Draft*

What is unique about this case, and what does it add to the scientific literature?

What are the primary diagnoses, interventions, and outcomes?

What are the patient's main concerns and/or important clinical findings?

What are the "take-away" lessons from this case report?

Research Requiring Submission*

Does your case report meet any of the following criteria?

1: The report involves three or more patients

2: The case report incorporates a systematic data analysis

3: The case report tests a hypothesis (e.g. treatment A is better than treatment B for this rare condition)

Select

ALERT!

If you answered YES to any of the above questions, your project is NOT a case report/series. Please return to the top of the form and select "research study" under scholarly activity. If you feel this project is an exception, please explain below.

Have you reviewed the CARE guidelines?*

https://www.care-statement.org/case-reports

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Problem Statement*

Study Goals*

Does the project involve human subjects?*

Is it necessary to access protected health information from patient charts to carry out this scholarly activity?

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Quality Improvement vs Research*

Do any of the following describe your project?

1: Implementation of a new intervention to improve patient care and analysis of data to establish scientific evidence of the intervention's effectiveness.

2: Implementation of a novel approach that has not been extensively studied

3: Development of new quality assessment or measurement tools

4: Use of patient data in order to develop new clinical treatment guidelines

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If yes, please explain in detail.*

Purpose*

Is the primary aim to: Improve care for the next patient seen? OR Improve operations or efficiency?

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Rationale*

Is there sufficient evidence for, or acceptance of, this mode or approach to support implementing this activity or to create practice change based on literature, consensus statements, or a consensus among the clinical team?

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Methods 1*

Are the proposed methods flexible and customizable, and do they incorporate rapid evaluation, feedback, and incremental changes?

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Methods 2*

Do the methods include any of the following? Control Group Randomization Fixed Protocol

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If yes, please explain the methods.*

Risk*

Is the risk related to the project minimal and no more than usual care (including the unavoidable minimal risk in implementing any changes made in process of care)?

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Participants*

Will the activity only involve participants who are ordinarily seen, cared for, or work at the setting where the activity will take place?

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Funding*

Is the project funded by any of the following: an outside organization with an interest in the results, a manufacturer with an interest in the outcome of the project relevant to its products, or a non-profit foundation that typically funds research, or by internal research accounts?

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If yes, please describe the funding source.*

Biostatistician Request

Check this box to request a consultation with the contracted biostatistician. This box should be selected for all original research studies at Western Reserve Hospital.

Are you interested in involving a medical student in this project?

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Faculty/Department Sponsor Name*

For lectures (such as grand rounds), please enter the appropriate department.

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Faculty/Department Sponsor - Approval Form*

Please upload your SIGNED faculty/sponsor approval form.

For lectures/teachings (such as grand rounds), please upload supporting documentation (PowerPoint, etc.) in place of a signed faculty form.

Drag and drop files here or

Identifying Title*

Include a brief title that will allow you to differentiate between multiple submissions. This title is for identification purposes in Smartsheet only. It will not be the final title.

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