HADSI Service Request Form

EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI)
Eastern Virginia Medical School
Service Request Form

Requests should be submitted at least 3 weeks prior to the expected deadline.
Projects will be prioritized by deadline date, number of services requested, and available funding for services.

Please do not submit multiple requests for the same project.
Additional documentation and/or revisions to existing projects should be sent via SendIt
to HADSI@EVMS.EDU with your service request number and requestor name.

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Y-M-D

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Principal Investigator Information

Yes No

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Yes

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Requestor Information

Yes No

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Abstract Preparation*

Data Analysis*

Database Design*

Publication Preparation*

Data Extraction

Database Management

Grant Submission**

IRB Assistance

Power Analysis

Protocol Development

Sample Size Calculation

Study Design

Survey Research

Other

Sentara EPIC

Sentara Cancer Registry

EVMS Allscripts

Other

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Yes

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M-D-Y

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This research is self-sponsored.¹

This research is required for training/graduation.¹

I am currently seeking funding for this project.²

¹A faculty principal investigator is required to be present at consultation(s).
²If you are currently seeking funding, please be sure to check all related services (listed in question #1) if the funding is awarded.

Please provide the following:

Study protocol or a draft of the protocol

IRB approval notice

List of variables collected or plan to be collected

Any existing data in Excel or Access format

Sample of questionnaire

Publications for work on which you wish to build

Terms and Conditions

Please read and accept the following terms and conditions of service:

1. Individuals in HADSI who make a substantial contribution to the design or analysis of a study are to be listed as authors on any resulting presentations/publications.

2. All authors will review the final version of the presentation/publication prior to submission.

3. If the project is funded, currently seeking funding, or will acquire funding, a percentage of the budget should be allocated to HADSI service (contact HADSI for further details).

Your below electronic signature certifies that you understand the agreements cited above and you are committed to fulfill these agreements.

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M-D-Y

For HADSI Only:

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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

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/^\d{10}$/

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/^\d{4}$/

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/^\d{5}(-\d{4})?$/

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HADSI Service Request Form

EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI)Eastern Virginia Medical SchoolService Request Form

Principal Investigator Information

Requestor Information

Terms and Conditions

For HADSI Only:

EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI)
Eastern Virginia Medical School
Service Request Form