CTSI Research Services Request Form

With the below definitions in mind, does this study address specific Translational Science challenges?

• Translational Research (TR) addresses a particular step of the translational process (T0-T4) for a particular target or disease with a specific outcome; and
• Translational Science (TS) addresses longstanding scientific and operational challenges through innovations that transform the way research is conducted, making it faster, more efficient, and more impactful.

For example, studies can be written as Translational Research and Translational Science. Below are two examples of those studies.

For more information, click the link on:  Translational Science Principles

What is the deadline for biostatistics input?
Requests with a 30-day or less notice period may not be considered, depending on current workload.

If other, please describe

If this project has not been reviewed by the aLHS Steering Committee, have you been working with any members of the Committee?

Which RFA are you applying to?
For more information on the pilot options, please visit the CTSI Pilot Program website

Please provide information on what you would like to discuss in the consultation.

Note: Consultations are to provide investigators with guidance on implementation study design; integration of theories, models and frameworks; implementation planning; mixed methods research; stakeholder engagement, and participatory research.

What type of Letter(s) of Support do you need from the CTSI?

If you need a Letter of Support drafted for a grant proposal that is not related to CTSI support, please select the Grant Editing service instead.

Please upload a copy of the protocol (Only full protocol drafts will be reviewed***)

Note - Only one protocol/study should be submitted per request. If you need assistance with multiple studies, please submit a Service Request for each one.

Is this project planning to engage more than one CTSI service line? For example: Biostatistical Support or the REDCap team

Please provide the i2b2 username, query name, and run date of the associated i2b2 query.

Please upload the list of MRNs

Please indicate which source system (Encompass, etc) the MRN list is from

Please list the Inclusion criteria.

Please consider the following elements:

• • Date range
  • Gender
  • Age (age at diagnosis/procedure/encounter)
  • Age (current age)
  • Patient source
  • Diagnosis (with ICD 9/10 codes)
  • Procedures (with CPT codes)

Please list the Exclusion criteria.

Please consider the following elements:

• • <18 years old
  • Diagnosis (with ICD 9/10 codes)
  • Procedures (with ICD 9/10 codes)

What is the approximate number of patients you think might qualify for this cohort definition? Ballpark is fine.

What data elements do you want extracted from this patient set?

Please include all data elements that you want included in your result file. We do not automatically include data associated with inclusion/exclusion criteria. For example, if a diagnosis is included in the inclusion criteria it will not automatically be included in the data set provided to you. If this is data needed, please make sure to specify that in this section. MRN is not automatically included, so please specify if that field is desired. Also please ensure the IRB associated with this study includes these elements.

Indicate how often and for how long

Do you have a strong preference for the end format of your data? For example, an excel or csv file

Please indicate the type of file you prefer

Please upload a sample output file, if you have one to share

If yes, please describe:

Please indicate the ServiceNow ticket this is associated with.

Will this data or its derivatives be shared outside the enterprise? (Please note this refers to sharing data, not sharing results of research through papers and presentations.)

Indicate what external entity will be receiving patient data.

If applicable, please enter the date you need to receive the data by (to give you enough time to meet a specific later deadline). For simple requests involving a single data source, the informatics team can typically fulfill the request within two weeks of beginning work on the request (which is dependent on the number of requests in the queue) . However, for more complex requests, or for requests that require additional consultation time before and/or after the data pull, more time will be needed. We will work with you as best we can to meet your timeline.