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u3aFf4sL2PmGp88FSwWPyAeKoYZikJPQquGrqTM7ZZ3VoIJXUeD6qreSZ6iH3ZSw9kAKWQJvMLhwCBhWVD88CY5RC2RKH5XEraM44tjiv4

Adult Ambulatory Services - Outpatient Research Form

Research projects that involve patients or staff in the Adult Ambulatory Services (this includes: General Adult Services, Lazos Fuertes, Deaf Wellness Clinic) within Psychiatry at URMC should be discussed with the Adult Ambulatory Research Committee and members of service leadership ideally before submission to the Research Subjects Review Board (RSRB) or any time afterwards. The goal is to assist with implementation of the research project.

Note: The Adult Ambulatory Research Committee meets on the third Friday of each month to review these proposals. If you need an earlier review, please contact us by email at AdultAmbulatoryResearchCommittee@urmc.rochester.edu after filling out this form.

1) Title of Project:

* must provide value

2) Proposed Start Date of Project:

* must provide value

M-D-Y

3) Proposed End Date of Project:

* must provide value

M-D-Y

4) Principal Investigator:

* must provide value

5) Co-Investigator(s):

6) Is this project quality improvement or research?

* must provide value

Quality Improvement Project

Research Project

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7) Is this project a clinical trial?

* must provide value

Yes

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8) Has the project been approved by RSRB?

* must provide value

Yes

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8a) If No, what stage is the project in?

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9) Has Adult Ambulatory staff been involved in your project?

* must provide value

Yes

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9a) If Yes, who and in what manner?

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10) Has the Patient and Family Advisory Council been involved?

* must provide value

Yes

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11) Please specify sources of funding for the project (choose all that apply):

* must provide value

URMC-formally funded pilot project

Psychiatry Departmental Funding

Other internal source

Other external source

No formal funding

11a) Other internal source (specify):

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11b) Other external source (specify):

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12) Which Adult Ambulatory Services does your project involve?

* must provide value

General Adult Services

Lazos Fuertes

Deaf Wellness Clinic

1) Please provide in 1-2 sentences the purpose of the project:

* must provide value

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2) Participant recruitment: specify the target population, which services will be involved, anticipated number of participants in project protocol, and how recruitment will be carried out.

* must provide value

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3) Scheduling at URMC site: specify the number, timing, and duration of the research sessions.

* must provide value

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4) Specify any interventions provided:

* must provide value

Therapeutic

Medication

Other interventions

None / Not Applicable

4a) Therapeutic: specify intervention, target group, schedule and who will be providing the intervention.

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4b) Medication: specify what medication, target group, dose, cost (if medication is provided free then continued after the project is complete, what is the plan to address this).

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4c) Other Intervention: specify

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5) Use of any incentives: specify any incentives provided to participants, including the amount, type of incentive, and plan for distributing the incentive. Discuss how any potential or previous issues regarding the use of incentives will be addressed.

* must provide value

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6) Will your project need help from Adult Ambulatory staff in some manner?

* must provide value

Yes

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6a) If Yes, specify which staff, their role in the project, and the nature of their involvement.

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7) Will you utilize/access patient medical records for this project

* must provide value

Yes

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7a) If Yes, specify how the participant medical records will be used for this project.

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8) Will any data be entered into the medical record?

* must provide value

Yes

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8b) If Yes, specify:

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9) Will any of the following additional URMC facilities be required as part of this project (check all that apply)?

* must provide value

Imaging

EKG

Consultation services from outside the department

Phlebotomy

Other lab testing

None / Not Applicable

9a) Imaging: specify imaging needed.

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9b) Consultation services from outside the department: specify services needed.

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9c) Phlebotomy: specify if samples will be processed internally or externally.

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9d) Other lab testing: specify.

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Contact Name:

* must provide value

Contact E-mail:

* must provide value

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