Before filling out the HADSI Service Request form, please review the requirements to be eligible for free HADSI services:
For full-time EVMS salaried faculty (PI), up to two free projects. Any additional projects will be charged. EVMS fellows and residents (PI), first project will be free of cost, second will depend upon the available resources. Any additional projects will be charged. EVMS Students will only be accepted with their EVMS supervisor as the PI. PI will follow #1 requirement. For all grant-funded projects, HADSI services will be charged. HADSI Services Fees $80/hr for MPH level HADSI staff $110/hr for Ph.D. level HADSI staff Note: HADSI Pilot Funded projects do not count toward the total number of free HADSI services.
Based on the requirements listed above, are you eligible to receive HADSI services?
Yes
No
EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI) Service Request Form
Date of Request:
* must provide value
Y-M-D
Deadline Date:
* must provide value
Y-M-D
Please provide a deadline date. Keeping in mind that if EPIC data is needed, it will require at least 3-6 months notice.
* must provide value
Project Title:
* must provide value
Principal Investigator Information Last Name:
* must provide value
First Name:
* must provide value
Title:
* must provide value
MD PhD MD, PhD DO Master's Other
Please enter your title here:
* must provide value
Affiliation:
* must provide value
EVMS Sentara Other
Please enter your affiliation here:
* must provide value
Position:
* must provide value
Faculty Fellow Resident Staff Student Other
Supervisor/Mentor Name
* must provide value
Supervisors or mentors are required to attend all initial meetings with PI and HADSI.
Supervisor/Mentor Email
* must provide value
Please enter your position here:
* must provide value
Faculty Type:
* must provide value
Full-time EVMS Salaried Full-time EVMS Non-salaried EVMS Community Faculty Part-time EVMS Salaried Part-time EVMS Non-salaried Emeritus Salaried Emeritus Non-salaried Other
Please enter your faculty type here:
* must provide value
Department:
* must provide value
Art Therapy & Counseling Biomedical Sciences Biotechnology Dermatology Emergency Medicine Family & Community Medicine Geriatrics and Gerontology Internal Medicine Laboratory Animal Science Leroy T. Canoles Jr. Cancer Research Center Medical Master's Medical & Health Professions Education Medical School - Student Microbiology & Molecular Cell Biology Neurology Obstetrics & Gynecology Ocular Pharmacology Ophthalmology Otolaryngology Pathologists' Assistant Pathology & Anatomy Pediatrics Physical Medicine & Rehabilitation Physician Assistant Physiological Sciences Psychiatry & Behavioral Sciences Public Health Radiation Oncology & Biophysics Radiology Reproductive Clinical Science Research Subjects' Protections Surgery Surgical Assistant Urology Other
Please enter your department here:
* must provide value
Phone Number:
* must provide value
Email:
* must provide value
Please provide your institution (e.g. @evms.edu) email address.
Is this project for a graduation requirement?
* must provide value
Yes No
Are you the principal investigator in this study?
* must provide value
Yes
No
Last Name:
* must provide value
First Name:
* must provide value
Title:
* must provide value
MD PhD MD, PhD DO Master's Other
Please enter your title here:
* must provide value
Affiliation:
* must provide value
EVMS Sentara Other
Please enter your affiliation here:
* must provide value
Position:
* must provide value
Faculty Fellow Resident Staff Student Other
Please enter your position here:
* must provide value
Is this required for graduation?
Yes No
What year do you graduate?
Faculty Type:
* must provide value
Full-time EVMS Salaried Full-time EVMS Non-salaried EVMS Community Faculty Part-time EVMS Salaried Part-time EVMS Non-salaried Emeritus Salaried Emeritus Non-salaried Other
Please enter your faculty type here:
* must provide value
Department:
* must provide value
Art Therapy & Counseling Biomedical Sciences Biotechnology Dermatology Emergency Medicine Family & Community Medicine Geriatrics and Gerontology Internal Medicine Laboratory Animal Science Leroy T. Canoles Jr. Cancer Research Center Medical Master's Medical & Health Professions Education Medical School - Student Microbiology & Molecular Cell Biology Neurology Obstetrics & Gynecology Ocular Pharmacology Ophthalmology Otolaryngology Pathologists' Assistant Pathology & Anatomy Pediatrics Physical Medicine & Rehabilitation Physician Assistant Physiological Sciences Psychiatry & Behavioral Sciences Public Health Radiation Oncology & Biophysics Radiology Reproductive Clinical Science Research Subjects' Protections Surgery Surgical Assistant Urology Other
Please enter your department here:
* must provide value
Phone Number:
* must provide value
Email:
* must provide value
Please provide your institution (e.g. @evms.edu) email address.
Do you currently have any active service requests with HADSI?
Yes
No
Please list the service request numbers of all active projects you have with HADSI.
Service request numbers are typically in the form SRXXXX (Last Name, First Name) and are provided via e-mail when the project is assigned.
Is this a student-led project?
Yes
No
1. Type of Service Request:
* must provide value
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
*IRB approval is required. **Grant submission requires 3 months notice.
To request grant writing services, please fill out the online form located below:Grant Services Request Form **Grant writing services must be submitted at least 3 months prior.
Data Source:
* must provide value
Sentara EPIC
Sentara Cancer Registry
EVMS Allscripts
Virginia Health Information (VHI)
Other
Data extraction from EPIC will require more than 3 months.
Please Describe:
* must provide value
Please Describe:
* must provide value
2. Do you have IRB approval?
* must provide value
Yes
No
Please provide IRB#:
* must provide value
Expiration Date:
M-D-Y
3. Does this project have any type of funding?
* must provide value
Yes
No
Please provide grant # and funding source:
* must provide value
Please select all that apply:
* must provide value
This research is self-sponsored.1
This research is required for training/graduation.1
I am currently seeking funding for this project.2 1 A faculty principal investigator is required to be present at consultation(s).2 If you are currently seeking funding, please be sure to check all related services (listed in question #1) if the funding is awarded.
Are you seeking HADSI Pilot Funding or other internal/external grant?
HADSI Pilot Funding Other grant
If other grant, please provide the following:
Length of Grant, Period of Study:
* must provide value
Funding agency (e.g. CDC, NIH...):
* must provide value
4. Please attach all applicable document(s):
* must provide value
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
Other documents related to the project
*If no protocol has been drafted, HADSI requires that investigators
Attach Protocol Here
* must provide value
Attach IRB Approval Letter Here
* must provide value
Attach List of Variables Here
* must provide value
Attach Existing Data Here
* must provide value
Attach Sample of Questionnaire Here
* must provide value
Attach Publication Here
* must provide value
If more than one publication, please check 'Other documents related to this project.'
How many other documents do you need to submit?
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
Attach Other Document Here
* must provide value
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).
I agree to the terms and conditions of service.
* must provide value
Your below electronic signature certifies that you understand the agreements cited above and you are committed to fulfill these agreements.
Signature:
* must provide value
Name:
* must provide value
Date:
* must provide value
M-D-Y
Research Evaluation QA/QI
Yes
No
Definition: Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.
Yes
No
Definition: Syndemic theory focuses on the adverse interactions between diseases and social conditions, specifically drawing attention to the mechanisms of these interactions. The term syndemic is the aggregation of two or more concurrent or sequential epidemics or disease clusters in a population with biological interactions, which exacerbate the prognosis and burden of disease.
Cancer Cardiovascular Disease Maternal and Child Health Mental Health Opioid COVID-19 Two or More Areas None of the Above
Will HADSI service(s) be free of charge for this project?
Yes
No
Current Primary Contact: Last Name
Current PI or primary person responsible for project
Current Primary Contact: First Name
Primary HADSI Staff Member
Sarah DePerrior Ismail El Moudden Brynn Sheehan Angela Toepp Reem Sharaf Alddin Amanda Clarke Marilyn Bartholmae Esther Stephens Sunita Dodani Fang Fang Matt Karpov Michael Bittner
Secondary HADSI Staff Member
Sarah DePerrior Ismail El Moudden Brynn Sheehan Angela Toepp Reem Sharaf Alddin Amanda Clarke Marilyn Bartholmae Esther Stephens Sunita Dodani Fang Fang Matt Karpov Michael Bittner
Non-Sentara
Sentara
Yes
No
(Did they submit a LOI?)
Yes
No
(Project selected for HADSI Funding)
Does project have other type of funding?
* must provide value
Yes
No
Format SRXXXX
Today M-D-Y
Today M-D-Y The date when the project was closed.
