CUHCC Quality Improvement \"&\" Research Application v2

CUHCC Quality Improvement & Research Application

Please complete this application if you're interested in a Quality Improvement or Research Project at CUHCC. Someone from the Quality or Research teams at CUHCC will follow-up with you after your application is submitted.

1. Is this a change to a previous application?*

Yes

Contact Information

2. First Name:*

3. Last Name:*

4. Phone Number:

Phone

5. Email: *

6. Are you affiliated with the University of Minnesota?*

Yes

6a. What is your organization?*

7. Are you a learner?*

Yes

7a. Are you a current or do you plan on becoming a learner at CUHCC?*

Yes

7a-1a. If 'Other' area, please specify:*

7a-2. Who is your CUHCC Preceptor?*

7b. Do you have a project mentor (Principal Investigator or Advisor of Student Investigator) ?*

Yes

7b-1. What is your project mentor's name?*

7b-2. What is your project mentor’s email?*

7b-3. Is your project mentor at CUHCC?*

Yes

7b-3a. If 'No', please specify what organization your project mentor is from:*

8. Projected Start Date:*

9. Projected End Date:*

Quality Improvement Versus Research

Research = Human Subjects involved

Quality Improvement = No Human Subjects Involved

Resources:

U.S. Department of Health & Human Services

Human Subject Regulations Decision Charts: 2018 Requirements

UMN

503: Human Research Determination Form

Student-Investigators should create the ETHOS submission, but their Advisor will submit the Determination Form (HRP-503).

UMN Investigator Manual, Page 24

Project Type

10. Is your project:*

Research

Quality Improvement

Instructions for Researchers and Student-Researchers

Each research application is reviewed by the CUHCC Research Infrastructure Team.

After the team has reviewed your completed application, you will receive one of the 3 of the following notifications:

Denied - with reasons
Accepted
Pending with additional questions

CUHCC's Research Standards include:

The research is a benefit to our patients and community
The research design is of acceptable quality
All resources necessary to complete the project are accounted for, and, the cost to CUHCC is negligible
The project does not interfere with patient services
The project is judged as acceptable to our patients
There is a mechanism for ongoing review and discussion between the investigator and CUHCC regarding the evaluation, interpretation, and dissemination of the results
The timing of the project does not conflict with other clinical and research projects already scheduled
The overall potential benefit of the project outweighs the known or potential costs and risks

For questions regarding Research, please contact: Shannon Pergament at perg0002@umn.edu

11R. IRB Application Type:*

Social-Behavioral

Biomedical

13R. IRB #:*

14R. Name of Principal Investigator (PI):*

15R. Project Short Title:*

Summary of Project

You may also attach files below in addition to Questions 16Ra-g.

16Ra. Research Question*

16Rb. Research Aims*

16Rc. Specific requests/asks of CUHCC*

16Rd. Please explain how you have sought community expert/patient insight into your research plan and to what extent you plan to continue to do so.*

16Re. Anticipated benefit to community:*

16Rf. Anticipated benefit to patients:*

16Rg. Please explain your plan for how you will disseminate your research findings back to the community.*

17R. Are you willing to showcase your study at CUHCC (i.e. poster session)?*

Yes

18R. Do you agree to share your study findings and dissemination products with CUHCC?*

Yes

19Ra. If requesting 'Recruitment', please select how:*

Posting fliers for recruitment

CUHCC providers/staff help with recruitment

Study team on-site at CUHCC for recruitment

19Rb. If requesting data, please select which statement applies to you.*

I am requesting a de-identified dataset and have an HST issued computer.

I am requesting a de-identified dataset and do NOT have an HST issued computer.

I am requesting a identified dataset and have an HST issued computer.

I am requesting a identified dataset and do NOT have an HST issued computer.

I am not sure.

19Rc. If requesting 'Other', please describe:*

20Ra. If requesting 'Other', please describe:*

21Ra. What is your grant mechanism?*

21Rb. What is your submission deadline?*

21Rc. What is your maximum award?*

21Rd. What is your proposed project timeline?*

22R. Summary of Budget for CUHCC Involvement.*

You may also add this as an attachment.

23R. Are you looking to partner with SaLaHmo?*

About SoLaHmo: https://cuhcc.umn.edu/education-and-research/solahmo

Yes.

No.

23R-S. What type of collaboration with SoLaHmo are you seeking?*

Note for Community Based Participatory Research Partnership (CBPR): Community-academic research partnership in all aspects of the study.
Note for Consulting Arrangements - SoLaHmo does not provide translation services or help with recruitment outside of a more robust collaboration.

Community Based Participatory Research Partnership (CBPR).

Consulting Arrangement.

Something Else.

23R-Sa. If requesting a 'Consulting Arrangement', please select all relevant activities.*

CARE Session (Community Academic Research Engagement Session): 1-3 community-centered consultation sessions on the conceptualization, design and implementation of a study and strategies for genuine community engagement.

Active Collaboration: Help with development culturally resonant research documents, qualitative data collection and culturally resonant participatory data analysis.

Active Collaboration: Training/Facilitation.

Active Collaboration: Other.

23R-Sa1. If requesting, 'Training/Facilitation', please describe:*

23R-Sa2. If requesting, 'Other', please describe:*

23R-Sb. If requesting 'Something Else', please describe:*

24R-S. How did you hear about SoLaHmo?*

Instructions for Quality Improvement (QI) Projects

Once the Human subjects determination form and this application are completed, the Quality Team will set-up an initial meeting with the individual who submitted the application.

Quality Projects will be approved for learners that are currently a learner or who are planning to be a learner at CUHCC during the time of their project. All other projects will be denied

For questions about Quality Improvement Projects, please contact: cuhccquality@umn.edu

11Q. Is this QI project required for your educational program?*

Yes

12Q. How many hours per week (average) will you be able to spend on the project?*

13Q. What is the topic of your QI project?*

14Q. What date is your final project product due to your department?*

i.e. paper, presentation

QI - Please upload (if applicable):

Objectives / deliverables /and any mini milestone deliveries needed
QI proposal
Human Subjects Determination Approval
Other documents

Research - Please upload (if applicable):

Your Project's Protocol
A Summary of your Project.
A Summary of your Proposed Budget for CUHCC Involvement.

File Upload

Drag and drop files here or

Any other information you would like to provide.

Optional

Send me a copy of my responses

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