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Abstraction work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Abstraction work completed:
Yes No Pending
M-D-Y
Advarra EDC work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Informatics work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Data Entry work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Data Pull work completed:
Yes No Pending
Completion date:
(Managers of statisical services and/or Abstraction will be notified when the date is entered)
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Data/Specimen Collection work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
REDCap New Project intake survey sent:
Yes No
REDCap Intake Survey number
Yes No Not Applicable - Self-build
Name of team member assigned to project:
Assigned team member's email address:
M-D-Y
Yes No Pending
REDCap work completion date:
M-D-Y
Reason service was not assigned
Epidemiology work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Grant Proposal work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
PHS Marketing work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Interviewing work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Lab services work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Focus Group work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Project coordination work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Recruitment work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Statistical Expertise work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Statistical Expertise work completed:
Yes No Pending
M-D-Y
Assigned team member's email address:
Reason service was not assigned
Preparatory Research work assigned:
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason service was not assigned
Yes No Pending
M-D-Y
Name of team member assigned to project:
Reason ______ service was not assigned
M-D-Y
First Name
* must provide value
Last Name
* must provide value
Business Unit
* must provide value
HAP Henry Ford Hospital Henry Ford Allegiance Henry Ford Corporate Henry Ford Macomb Henry Ford West Bloomfield Henry Ford Wyandotte Behavioral Health Other
If Other Location is selected, enter the name of your location:
Department / Division
* must provide value
Academic Affairs Acute Care Administration After Hours Care Allergy Anesthesiology Audiology Bioresources Bone & Mineral Metabolism Cardiology Center for Academic Nursing Center for Clinical Effectiveness Center for Health Policy and Health Services Research Center for Health Promotion and Disease Prevention Center for Integrative Wellness Central Credentialing Services Clinical Systems Research & Integration Dentistry Dermatology Emergency Medicine Employee Health Endocrinology Diabetes Bone and Mineral Disorders Eye Care Services Family Medicine Gastroenterology / Hepatology Geriatrics Government Affairs Gynecology Obstetrics & Womens Health Health Risk Outreach Heart & Vascular Institute Hematology / Oncology Henry Ford At Home Henry Ford Cancer Institute Henry Ford QuickCare HFMG Administration HFMG Staff Services Home Health Care Hospice Hospital Administration Hypertension Infectious Disease Information Strategies Physician Service Information Technology Innovation Institute Integrative Medicine Internal Medicine Internal Medicine/Pediatrics Medical Education Medical Genetics Medical Staff Affairs & Physician Practice Development Nephrology Neurological Surgery Neurology Nursing Administration Occupational Health Office of Clinical Quality & Safety Office of Public Policy Innitiatives Ophthalmology/Eye Care Orthopaedic Surgery Otolaryngology - Ear, Nose & Throat Pathology and Laboratory Medicine Patient Care Services Pediatrics Pharmacy Prevention Psychiatry/Behavioral Health Public Health Sciences Pulmonary Quality Support Services Radiation Oncology Radiology Rehabilitative Medicine Research Administration Rheumatology Sleep Disorders Center Surgery Urgent Care Urology Walk In Clinic Women's Health Other
If Other Department is selected, enter the name of your department:
Email Address
* must provide value
Henry Ford Health System corporate email address only
Primary Investigator first name
* must provide value
Primary Investigator last name
* must provide value
Primary Investigator Department / Division
* must provide value
Academic Affairs Acute Care Administration After Hours Care Allergy Anesthesiology Audiology Bioresources Bone & Mineral Metabolism Cardiology Center for Academic Nursing Center for Clinical Effectiveness Center for Health Policy and Health Services Research Center for Health Promotion and Disease Prevention Center for Integrative Wellness Central Credentialing Services Clinical Systems Research & Integration Dentistry Dermatology Emergency Medicine Employee Health Endocrinology Diabetes Bone and Mineral Disorders Eye Care Services Family Medicine Gastroenterology / Hepatology Geriatrics Government Affairs Gynecology Obstetrics & Womens Health Health Risk Outreach Heart & Vascular Institute Hematology / Oncology Henry Ford At Home Henry Ford Cancer Institute Henry Ford QuickCare HFMG Administration HFMG Staff Services Home Health Care Hospice Hospital Administration Hypertension Infectious Disease Information Strategies Physician Service Information Technology Innovation Institute Integrative Medicine Internal Medicine Internal Medicine/Pediatrics Medical Education Medical Genetics Medical Staff Affairs & Physician Practice Development Nephrology Neurological Surgery Neurology Nursing Administration Occupational Health Office of Clinical Quality & Safety Office of Public Policy Innitiatives Ophthalmology/Eye Care Orthopaedic Surgery Otolaryngology - Ear, Nose & Throat Pathology and Laboratory Medicine Patient Care Services Pediatrics Pharmacy Prevention Psychiatry/Behavioral Health Public Health Sciences Pulmonary Quality Support Services Radiation Oncology Radiology Rehabilitative Medicine Research Administration Rheumatology Sleep Disorders Center Surgery Urgent Care Urology Walk In Clinic Women's Health Other
Project Title
* must provide value
Cost Center or Grant Number associated with this project for applicable charges
Cost Center or Grant number is not applicable
Please indicate if this is a COVID-19 related project * must provide value
Yes
No
Upload any relevant project information here
Does your project involve an Investigational New Drug (IND) or Device Exemption (IDE), or is the FDA or a Pharmaceutical Company sponsoring your project?
Yes
No
Was an Institutional Review Board, (IRB), number granted?
* must provide value
Yes
No
NA
Please indicate why an Institutional Review Board, (IRB), number was not granted?
If IRB is in process, please enter "Pending".
* must provide value
M-D-Y
M-D-Y
Please upload a copy of the IRB application/consent with a stamped approval
Please upload IRB protocols:
Please upload IRB materials:
Was an Institutional Animal Care and Use Committee, (IACUC), number granted?
* must provide value
Yes
No
NA
IACUC approved start date:
M-D-Y
M-D-Y
Please upload a copy of the IACUC application/consent with a stamped approval
Please upload IACUC protocols:
Please upload IACUC materials:
Please upload a brief description of your project and any relevant documents (i.e. design document, partially completed IRB/IACUC, etc...)
Please upload any additional documents regarding your project
Please upload any additional documents regarding your project
Is this a GME request?
* must provide value
Yes No
Provide EMR data to Medical Education researchers for IRB approved study.
HFHS Graduate Medical Education (GME) Request Form
Please use the following link to download the GME form. It is required that the GME form be completely filled out with mentor's and chair's approval, including both signatures . (Upload the completed GME form, with all additional requested documents, in the next GME upload links)
Upload the approved GME Form, with signatures, using the following link
Upload additional GME documents, using the following link
Have you discussed this project with a Public Health Sciences (PHS) staff member?
* must provide value
Yes
No
I am not sure where to start. Please have a PHS staff member contact me
Email address of PHS member
All PHS collaborations descriptions
Specialized Expertise
Statistical Expertise Grant/Proposal Development Epidemiological Expertise Marketing Patient Engaged Research Center and Focus Groups Project Coordination Informatics Expertise GIS, Geographic Information System (GEO Coding)
Patient Advisor Placement Form (To obtain PERC services complete the following questionnaire. Please note, all questions are NOT required. After the submission of this request form, a PERC Team Member will contact you. Thank you.) PERC (Patient Engaged Research Center)
What is your Project/Council/Committee called?
PERC Collaboration options
What PERC Services are required?
Why is this group important? How does it relate to HFHS? Please be as detailed as possible
If Patient Advisor collaboration is needed, what role would the Patient Advisor play?
If Patient Advisor collaboration is needed, what work will the advisor be asked to perform?
Are there any eligibility requirements your Advisors must have?
Yes
No
American Indian or Alaska Native
Asian
Black or African-American
Middle Eastern
White
Other
If Other race is selected, please specify
18-29
30-44
45-64
65 and over
Female
Male
Transgender
Gender nonconforming
Please indicate any specific skills the advisor need
Indicate timeline of project below:
M-D-Y
M-D-Y
Do you have grant funding?
Yes No
Do you plan to apply for grant funding?
Yes No
Do the advisors need any special skills or training? Discontinued question 3/4/2021
Who will the advisors be working with? (Assigned Buddy) Who else is on the team? Discontinue question 3/4/2021
How much time will the advisors need to commit? Will there be meetings? Phone or in-person meetings? Discontinue question 3/4/2021
If applicable, what are planned meeting locations? Discontinue question 3/4/2021
Will the advisors be paid for their time? Please note, you do not have to pay advisors, most of your advisors are volunteers. Discontinue question 3/4/2021
Data Pull
Electronic Data Pull (EMR/Vital Data) National Surgical Quality Improvement Program (NSQIP) PHS Abstractor Chart Review
PHS Abstractor Chart Review Description
Credentialed data collection abstractors read the EMR to identify and collect data that cannot be pulled electronically by reviewing documents in EPIC. They are experts in reading and collecting data from various sources in the EMR including physician notes, health histories, operative notes, pathology reports, radiology reports, lab reports, discharge summaries, consults and inpatient stays. Database Build - Advarra EDC
Database Build - Advarra EDC Description
If your project involves an Investigation New Drug (IND) or Device Exemption (IDE), or if the FDA or a Pharmaceutical Company is sponsoring your project, it may require a 21 CFR Part 11 compliant database such as the Advarra EDC System.
Data Entry Description
Staff take time to accurately review and enter data, scan forms, and verify information. Electronic Data Pull (EMR/Vital Data)
Electronic Data Pull (EMR/Vital Data) Description
Programmatically retrieve patient data from Epic and other sources.
Data/Specimen Collection Description
Team Members are trained to collect survey data along with biospecimens ranging from blood, urine, swabbing and more in our clinics, hospitals, and designated research space. Database Build - Microsoft Access
Database Build - Microsoft Access Description
Develop and support Microsoft Access and Web based tools to facilitate medical record abstraction and patient survey tracking.
Database Build - REDCap Description
REDCap is a secure web application for building and managing online surveys and databases. PHS offers 2 models of REDCap support. The 1st is a "DIY" model with the one-time project setup fee of $300, which includes training and support. In the 2nd model, the REDCap team builds the database at the rate of $77.00 per hour. You will have the option to select the service in the REDCap new project intake form, which will be sent upon submission of this PHS survey. Epidemiological Expertise
Epidemiological Expertise Description
The master's and doctoral trained staff members have expertise in epidemiologic methods, including genetics, and the epidemiology of cancer, respiratory, cardiovascular and neurologic diseases. Their areas of expertise include: 1) Study Design: The Research Epidemiology Division collaborates with investigators in study design and development of study protocols, particularly for observational studies. They are trained to design studies that take into account the potential biases that can occur in a non-randomized study. They also assist with the design of the forms and questionnaires, which will be used to record information in the study. 2) HFHS Database Analyses: Staff members are proficient in the manipulation of managed care databases and the databases included in Henry Ford Health System's Corporate Data Store (CDS). They are experienced in identifying patient populations of interest, profiling practice patterns and providing descriptive information related to specified study interests.
Focus Groups Description
Small group interview with patients/caregivers to gather thoughts and feedback on certain topics. PERC can help develop a moderator of questions to ask participants. We also will note take and/or record conversation and have transcribed. GIS, Geographic Information System (Geocoding)
GIS, Geographic Information System (Geocoding) Description
Geocode and analyze to support studies based on US census-based neighborhood SES health behaviors and outcomes. Grant Proposal Development
Please specify-
* must provide value
To provide assistance from a PHS grant manager with a grant submission.
To provide assistance with budget development in which a PHS staff member is a part of an upcoming grant submission, requesting salary information or budget only.
Grant Proposal Development Description To provide assistance with budget development in which a PHS staff member is a part of an upcoming grant submission. To provide assistance with PHS faculty on grant submissions. Please specify in field below. Informatics Expertise (Biological or Medical)
Informatics Expertise (Biological or Medical) Description
The staff and faculty of the HFHS Center for Bioinformatics have expertise in large data analytics, including both molecular data and medical informatics. 1)Molecular informatics: Projects include familial genetics, genome-wide association studies, genomics, epigenomics / DNA methylation, transcriptomics, metabolomics, proteomics, and microbiome analysis. Both bulk and single-cell sequencing can be accommodated. Team members support project planning, upstream data preparation, and downstream analysis. 2)Medical informatics: Projects include quality analytics and predictive modeling using data from EPIC/Clarity and other electronic sources. Team members support project planning, data aggregation, and analysis. Interviewing (Enrolled Research Study
Participants)
Interviewing (Enrolled Research Study Participants) Description
Staff members conduct face to face and telephone interviews for research data collection using multiple online tools and methods for accurate data.
Lab Services Description
The laboratory offers the following areas of expertise and capabilities: 1)Sample recording, tracking, processing and storage, integrated into PHS databases. 2)Nucleic Acid (DNA, RNA) isolation. 3)Flow cytometry for cellular markers, cell cycle, apoptosis and exosomes 4)ELISAs and other biochemical assays. 5)BioPlex Luminex to measure expression of cytokines and chemokines. NSQIP (National Surgical Quality Improvement
Project)
NSQIP (National Surgical Quality Improvement Project) Description
Provide analyzed aggregate data from ACS NSQIP dataset for research purposes. PERC (Patient Engaged Research Center)
(If selected, please refer to the PERC section below)
PERC (Patient Engaged Research Center) Description
PERC services include: Focus Groups, One-on-One Interviews, Patient & Family Advisory Council Development, Patient/Caregiver Committee Placements, Survey Development & Distribution, Recruitment and Patient Centered Research Design. By selecting PERC, you are interested in engaging with Patient Advisors. You will receive a separate form via email to complete the PERC request. The additional PERC form will include more descriptions. Once all forms are submitted, a PERC Team Member will schedule an intake meeting with you to discuss next steps.
Project Coordination Description
Project coordinators provide regulatory reporting for the proposed study (e.g.; IRB) and maintain all study protocols, they will track completeness of incoming data, manage the programming, data collection and laboratory activities of the study and ensure timely provision of study stipends to participants. Recruitment Services for Study Participants
Project Recruitment and Retention services Description
Using strong customer service and communication skills helps staff in the field introduce a project and explain the importance of a study and help participants feel confident in joining our research. Follow Up calls, Mailers such as Newsletters and Birthday cards, scheduling, interviewing, tracking and tracing during the lifetime of the project. Retention Services for Study Participants
Retention Services for Study Participants Description
Follow Up calls, Mailers such as Newsletters and Birthday cards, scheduling, interviewing, tracking and tracing during the lifetime of the project. Statistical ExpertisePlease specify the specific services needed (select all that apply) *must provide value
Please specify the specific services needed.
* must provide value
Statistical Expertise (Data Analysis, Proposal Development) Description
The foundation for the Department's activities centers on collaboration between a team of master's and doctoral trained biostatisticians experienced in the areas of applied and theoretical statistics. Together, the staff participates in many aspects of research: 1) Study Design: In this phase of research, the staff collaborates on designing the experiment, addressing sample size requirements and developing data collection methods. 2) Data Analysis: This is the primary activity of the Biostatistics Division, with emphasis on proper methodology and communication of the results to the investigator in an understandable form.
PHS Marketing Description
Our group provides expertise on the communications and marketing aspects for research projects. We leverage relationships with our HFH Corporate Marketing partners and HFH Preferred Vendors to fulfill go to market strategies, communications assets, promotional items, and creative services.
Other Services Description
All other requests for collaboration that are not listed above. Please provide details in the comment section of your request. If Other, please describe
Interviewing (Enrolled Research Study Participants)
Project Recruitment and Retention services
Preparatory to Research (Only counts will be shared; no PHI will be shared without an approved IRB) Preparatory to Research(Only counts will be shared; no PHI will be shared without an approved IRB)
Preparatory to Research Description
This service is available to PHS staff only. Data team provides counts without any PHI for IRB preparation, grant preparation or identifying cohort for studies, etc."
Please Indicate other service needed
AT LEAST ONE CATEGORY OPTION MUST BE SELECTED
(Please make a selection)
NSQIP Data Request Process
Public Health Sciences (PHS) has acquired the National Surgical Quality Improvement Project (NSQIP) Dataset with the approval of HFHS Surgical Champions- Dr. Ilan Rubinfeld and Dr. Joe Patton. All involved operational personnel have signed the ACS data user agreement. Data is assembled and housed on a secure and dedicated SQL server maintained by PHS department for data stewardship.
The earliest data available is from 2005 onwards. Some of the variables have been modified by ACS over the years and all variables requested may not be available for the requested time frame. Key points to keep in mind before requesting data-
1. Data Request will NOT be entertained without an approved IRB and a complete PHS request form
2. Mention appropriate procedure [CPT and/or HCPCS] codes
3. Individuals are NOT allowed to request data directly from ACS NSQIP. Only analyzed data will be delivered.
4. You ACKNOWLEDGE to include the following disclosure on any presentation or published material:
"The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors".
5. To request data please complete the Request Form https://phs.hfhs.org/redcap/surveys/?s=EJ9MKN3RFW
6. Data turn-around time is 3-4 weeks
7. In case of any questions, please email us at PHSRequests@hfhs.org
Note - After this form is submitted, another Request for Collaboration form will need to be filled out and submitted for any additional services needed for this project. Please email us at PHSRequests@hfhs.org for any questions regarding this request.
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