Your name:* must provide value
(first, last)
Your Email Address: * must provide value
HSD Number (aka IRB Number)
* must provide value
Principal Investigator Name:* must provide value
Principal Investigator email:* must provide value
Protocol Title: * must provide value
Short title:For ease of use in future communications regarding this request
* must provide value
25 characters max
Where is your research located?* must provide value
UWMC HMC Emergency Department (ED) UWMC Emergency Department (ED) HMC UWMC
HMC
Emergency Department (ED) UWMC
Emergency Department (ED) HMC
calc if this is a multisite study View equation
Is this an on-going protocol at UWMC implemented prior to the temporary halt on research due to COVID-19 pandemic?* must provide value
Yes No
Which unit(s) will your patient/participant be admitted? * must provide value
8NE (BMT Transplant)
8SE (Infusion Services)
8SA (Medical Oncology)
7NE (Medical Oncology/BMT)
7SE (Heme/Onc, Gyn/Onc, Uro)
7SA (Tx, Renal, Vasc/Gen Surg)
6NE (General Med,Family Med)
6SE (Orthopaedics, Ophthalmology)
6SA (Med Onc ICU)
5NE (Cardio, Surg.C, Telemetry)
5SE (Cardio Care ICU)
5SA (Cardiothoracic ICU)
4NE (Neuro, NS, Oto, Gen Surg)
4S (Special Procedure)
4SE (Observation and Short Stay)
4SA (Neonatal Intensive Care)
Other
8NE (BMT Transplant)
8SE (Infusion Services)
8SA (Medical Oncology)
7NE (Medical Oncology/BMT)
7SE (Heme/Onc, Gyn/Onc, Uro)
7SA (Tx, Renal, Vasc/Gen Surg)
6NE (General Med,Family Med)
6SE (Orthopaedics, Ophthalmology)
6SA (Med Onc ICU)
5NE (Cardio, Surg.C, Telemetry)
5SE (Cardio Care ICU)
5SA (Cardiothoracic ICU)
4NE (Neuro, NS, Oto, Gen Surg)
4S (Special Procedure)
4SE (Observation and Short Stay)
4SA (Neonatal Intensive Care)
Other
(check all that apply)
What "other" units/areas?
Is this an on-going protocol at HMC implemented prior to the temporary halt on research due to COVID-19 pandemic?* must provide value
Yes No
Which unit(s) will your patient/participant be admitted? * must provide value
In-patient ICU
In-patient units
Clinics
Other
In-patient ICU
In-patient units
Clinics
Other
Which ICU's?
2EH Medical/Coronary ICU
2WH Neurosciences ICU
9EH Burn/Pediatric ICU
9MB/MA Trauma/Surgical ICU
2EH Medical/Coronary ICU
2WH Neurosciences ICU
9EH Burn/Pediatric ICU
9MB/MA Trauma/Surgical ICU
Which In-patient units?
3E Medicine/Telemetry
3W Neurosurgery
4EH/Senior Care
4W Rehabilitation Medicine
5E Medical Surgical Specialties
6E Orthopedics
6MB Planned Surgery
7E General Surgery
8E Burn Plastic Reconstruction
3E Medicine/Telemetry
3W Neurosurgery
4EH/Senior Care
4W Rehabilitation Medicine
5E Medical Surgical Specialties
6E Orthopedics
6MB Planned Surgery
7E General Surgery
8E Burn Plastic Reconstruction
Which clinics?
Ground East Clinic (Cardiology, Diabetes/Endocrinology, Northwest Lipid)
Ground West Clinic (International Medicine, Pediatrics, Women's, Memory and Brain Wellness)
1 West Clinic (After Care, Orthopedic Trauma, Pain Relief Service)
1 West Clinic (Hansen's Disease Clinic, Infectious Disease, Madison Clinic, AIDS Clinical trial Unit)
3 West Clinic (Adult Medicine, Dermatology, High Risk Foot Clinic, Medical Specialties, Occupational Medicine Clinic, Rheumatology, Senior Care)
4 West Clinic (Audiology, Epilepsy, Ophthalmology, Oral and Maxillofacial Surgery, Otolaryngology)
8CT (Burns and Plastics)
4NJB (Sleep Center)
5NJB (Neurosurgery, Pre-Anesthesia, Sports & Spine, Surgical Spine, Stroke)
6NJB (Foot and Ankle Institute/Podiatry, Hand , Physical and Hand Therapy)
7NJB (Eye Institute)
11NJB (King County STD, Virology Research Clinic)
4MB (Comprehensive Outpatient Rehab Program (CORP), Neurology, Podiatry Clinic, Rehab Medicine, Thoracic Surgery, Vascular Surgery)
7MB (Chest, Chronic Fatigue, Gastroenterology, General Surgery, Hematology/Oncology, Hepatitis and Liver, Renal, Thoracic Surgery, Urology)
2Pat Steel (Family Medicine)
Downtown Program (Pioneer Square Downtown Program Third Avenue Center Downtown Program, Robert Clewis Center (2nd Avenue Clinic), Jefferson Terrace Edward Thomas House Medical Respite)
Ground East Clinic (Cardiology, Diabetes/Endocrinology, Northwest Lipid)
Ground West Clinic (International Medicine, Pediatrics, Women's, Memory and Brain Wellness)
1 West Clinic (After Care, Orthopedic Trauma, Pain Relief Service)
1 West Clinic (Hansen's Disease Clinic, Infectious Disease, Madison Clinic, AIDS Clinical trial Unit)
3 West Clinic (Adult Medicine, Dermatology, High Risk Foot Clinic, Medical Specialties, Occupational Medicine Clinic, Rheumatology, Senior Care)
4 West Clinic (Audiology, Epilepsy, Ophthalmology, Oral and Maxillofacial Surgery, Otolaryngology)
8CT (Burns and Plastics)
4NJB (Sleep Center)
5NJB (Neurosurgery, Pre-Anesthesia, Sports & Spine, Surgical Spine, Stroke)
6NJB (Foot and Ankle Institute/Podiatry, Hand , Physical and Hand Therapy)
7NJB (Eye Institute)
11NJB (King County STD, Virology Research Clinic)
4MB (Comprehensive Outpatient Rehab Program (CORP), Neurology, Podiatry Clinic, Rehab Medicine, Thoracic Surgery, Vascular Surgery)
7MB (Chest, Chronic Fatigue, Gastroenterology, General Surgery, Hematology/Oncology, Hepatitis and Liver, Renal, Thoracic Surgery, Urology)
2Pat Steel (Family Medicine)
Downtown Program (Pioneer Square Downtown Program Third Avenue Center Downtown Program, Robert Clewis Center (2nd Avenue Clinic), Jefferson Terrace Edward Thomas House Medical Respite)
What "other" units/areas?
Did you get approval from your sites (either ICU or clinic)? * must provide value
Yes No
Please provide us with names of the people that gave you permission:
Is this an on-going protocol at the ED implemented prior to the temporary halt on research due to COVID-19 pandemic?* must provide value
Yes No
Download and Complete the Returning to In-Person Research Plan/Checklist Complete and retain all relevant records that apply to your research, including the Checklist for Developing a Return to In-person Research Plan (Requirement #14)
Did you complete and retain all relevant records that apply to your research, including the Checklist for Developing a Return to In-person Research Plan (Requirement #14)
* must provide value
Yes No
What's the name of your COVID-19 supervisor?* must provide value
What's the lab of your COVID-19 supervisor?* must provide value
Can you limit two essential research staff (excluding the PI) coming to the hospital to engage/visit with the patient/participant admitted at the hospital? * must provide value
Yes No
Briefly explain why you need more than 2 essential research staff: * must provide value
How frequently will your essential research staff be coming to the hospital?* must provide value
2x day or less
3x day or more
2x day or less
3x day or more
Briefly explain why research staff are coming more than 2x per day * must provide value
How many research days are required for this protocol during the patient's/participant's admission?* must provide value
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
What activities must the research staff complete during the visit? * must provide value
Recruitment/Informed consent
Administer surveys
Drop-off documents
Drop-off kits
Pick up specimens
Other
None of the above
Recruitment/Informed consent
Administer surveys
Drop-off documents
Drop-off kits
Pick up specimens
Other
None of the above
(check all that apply)
Has pre-screening done remotely prior to coming to the hospital for recruitment? * must provide value
Yes No N/A
Is consenting remotely an option?* must provide value
Yes No
Can surveys be done remotely (over the phone, via zoom, on paper surveys or on a tablet)?* must provide value
Yes No
Which document(s) do you need to drop off? * must provide value
MD orders
Training logs
Stop-time logs
Lab requisitions
Other
MD orders
Training logs
Stop-time logs
Lab requisitions
Other
(check all that apply)
Can MD orders be faxed or emailed? * must provide value
Yes No
Can training logs be faxed or emailed? * must provide value
Yes No
Can infusion stop-time logs be faxed or emailed? * must provide value
Yes No
Can lab requisitions be faxed or emailed? * must provide value
Yes No
What "other" documents:* must provide value
Can these "other" documents be faxed or emailed?* must provide value
Yes No
How many kits are needed (count each timepoints)?* must provide value
Can the kits be dropped off in one batch?
NOTE:
All study kits must be separated by each day and time points All blood tubes and/or cryovials must be labeled and placed in a NON-biohazardous bag * must provide value
Yes No
Can the kits be delivered using courier services?* must provide value
Yes No
How often do you need to pick up specimen(s)? (Pick-up specimens from the soiled utility room if possible)
* must provide value
What "other" activities does the research staff need to complete during the visit?* must provide value
The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
What clinical activities are needed by the hospital staff? * must provide value
Vital Signs
Blood and/or urine specimens
ECGs
Study drug administration
Other
None
Vital Signs
Blood and/or urine specimens
ECGs
Study drug administration
Other
None
(check all that apply)
How often are vital signs needed?* must provide value
Who will do the vitals? * must provide value
Unit (floor) nurse
ITHS MTRU nurse
Study team staff
Unit (floor) nurse
ITHS MTRU nurse
Study team staff
How often are the specimens collected? * must provide value
Who will collect the specimens?* must provide value
Unit (floor) nurse
ITHS MTRU nurse
Study team staff
Unit (floor) nurse
ITHS MTRU nurse
Study team staff
How often are the ECGs done?* must provide value
Which machine will be used for the ECG?* must provide value
Unit machine
Sponsor provided machine
Unit machine
Sponsor provided machine
How often are the study drugs administered?* must provide value
Have you notified UW IDS?* must provide value
Yes No
What "other" clinical activities are needed for this protocol?* must provide value
How often are the "other" activities needed?* must provide value
Other than the personal face mask, do you anticipate additional personal protective equipment (PPE)? (i.e. isolation gowns, masks with shields)
* must provide value
Yes No
Please list additional PPE:* must provide value
We will notify you within 1-2 business day(s). In the meantime, please open the attachment and review the specific instructions on entering UWMC.