Requestor's Name:
Have you previously submitted a request to MIRI using this form? Yes
No
Role:
Department:
Contact Preference (enter phone or email):
Are you employed by MultiCare Health System?* must provide value
Yes
No
Check any that apply: I work at a MultiCare facility
I am new to research
I have been onboarded, trained and/or credentialed to work w/MIRI
I am an active MIRI researcher
I have some research experience
I am an experienced researcher
I am a credentialed MultiCare provider
Request Type (please select one)* must provide value
I have a general question I want to design/conduct a research study at MultiCare I have a question for the Librarian I have a data request I want to disseminate my project results I am looking for a collaborator I need something else I need help with an existing project I need support writing or planning a manuscript I need a targeted funding search
What do you need help with (select all that apply) I have an IRB related question
I need a protocol template
I have questions about my research design
I have a research design and project goals in mind
I need help figuring out how to get the work done
I'm not sure yet
Other
Please describe your request:
What type of support do you need from the Librarian? (check all that apply) I need help with a literature review
I need a copy of a journal article or book chapter
I need help identifying a target journal for my publication
I have a general request for the librarian
Please describe your request
Please enter your preferred contact information (phone or email):
What is your timeline for librarian support? If this is a patient care emergency and you need help within 2-4 hrs, please call (253) 403-3629 24 hrs 2 days within the week
What type of data support do you need? (check all that apply) I need help accessing EPIC data for a research project
I need help with a power analysis or general statistical support
I need a consultation with a statistician
I have an idea but no data
I have an idea and data
Please share your research and/or data questions for the statistician:
Describe the data you have and any additional data you need:
Tell us more about your project and what you are doing:
What type of dissemination support do you need? (check all that apply) I need help with writing or planning for a manuscript
I need help disseminating project results
Please tell us more about your project and what you need help with:
What stage are you at in the manuscript development (select all that apply): Outline
First Draft
Second Draft
Needing Data Analysis
Need help identifying a target journal
I need a literature review
Other
Please describe what you currently have prepared or provide key words/search terms to support your literature review:
Please describe what stage you are in the manuscript development process
What type of data support do you need? (check all that apply) I need help accessing EPIC data for a research project
I need help with a power analysis or general statistical support
I need a consultation with a statistician
I have an idea but no data
I have an idea and data
Are you working with a MultiCare researcher? Yes
No
Please provide researcher's name
Are you willing to mentor a MultiCare designated researcher? Yes
No
Are you willing to allow a MultiCare researcher to author papers with you using the data collected? Yes
No
Do you need MIRI to assist with identifying a site PI or research partner for your project? Yes
No
What is your education background (select all that apply?) MD
DO
PhD
PharmD
ScD
DBA
RN
BSN
ARNP
MPH
MS
MA
Other
What research experience and/or training do you have? (check all that apply) I am/have conducted clinical research in my practice
I am/have been a Principal Investigator or Co-Investigator on a federally sponsored grant
I have written extramural grants
I have received funding for my research
I received Human Subjects Protection Training
I received Good Clinical Practice Training
I received Conflict of Interest Training
I received Statistical Training
None, I am new at this
How many years of research experience do you have in conducting drug or device, clinical research, or other health related research? I am new to research (0 years)
I have some experience (1-3 years)
I have solid research experience (4-6 years)
I am a senior researcher (7+ yrs)
Upload your CV (optional)
Do you have a research question in mind? Yes
No
Which MultiCare system objective does this research project align with for current year? (select all that apply) Patient Safety
Quality
Improving Patient Care
Other
Unknown
Please describe how this project aligns with a MultiCare system objective:
Has the research design been written? Yes
No
Is there an IRB approved protocol? Yes
No
What do you currently have prepared? (check all that apply) Study Outline
Scope of Work
Hypothesis
Specific Aims
Other Documents
What is your project about? Please attach a 1-2 page summary or outline of your project.
Would you like to schedule a meeting to formulate or discuss a research idea/design? Yes
No
Would you like to schedule a meeting to discuss this collaboration? Yes
No
Please tell us more about your research idea:
Where will the research take place? (check all that apply) At a MultiCare Facility
At a Non MultiCare Facility
I'm not sure
Has the site been identified? Yes
No
What is the site name?
Has the site granted permission to conduct the proposed research project at their location? Yes
No
Do you need MIRI's help to identify and/or secure approval to use this location? Yes
No
Does your research study involve working with human subjects or accessing identifiable patient data? Yes
No
Would this be considered high risk, vulnerable or sensitive patient population? Yes
No
Not sure
What type of project are you seeking funding for? (select one option) Research Project
Community Project
Quality Improvement Project
I'm not sure yet
Tell us more about the type of project are you seeking funding for. Please attach a 1 page summary or outline of project.
What is your estimated budget for the project? (select all that apply) Under $10,000
$10,000 - $50,000
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
Over $500,000
$1,000,000 or more
I don't know
What is your expected project length? Please pick from the following options: Less than 1 year
Up to 1 year
Up to 2 years
Up to 3 years
Up to 4 years
Up to 5 years
5 years or longer
Will you need any specialized expertise, equipment or other resources to carry out this project? Yes
No
Tell us more about your specific requirements:
Please attach a copy of your CV or Biosketch
Is there funding for the proposed research project? Yes
No
If you have a draft budget, please upload a Word, PDF or Excel document here
Please select the funding source: Grant Funded
Industry Funding
Privately Funded
State funded
Unknown
Is this a new grant application or proposal? Yes
No
Do you need MIRI's assistance to identify a funding source or support a new grant proposal? Yes
No
When is the anticipated timeline to submit the proposal? Less than 30 days 30 days 1-2 months 2-4 months 4-6 months More than 6 months Unknown
What is the anticipated timeline to complete this request? Less than 30 days 30 days 1-2 months 2-4 months 4-6 months More than 6 months Unknown
Have you received approval from your department or supervisor to do this work? Yes
No
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