The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

zUU9pVUSoIfAbVJhLubdV4TvAVUzL2quFnPo4wXUBXgEh

RISE Service Request Form

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

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Additional resources:

If You Have a Question
Research Training and Resources
Student Office Hours

Research and Infrastructure Service Enterprise (RISE)
Service Request Form

In order to ensure adequate time for project planning and completion, we ask that students, residents, and fellows follow the RISE service timeline by contacting RISE at least one year prior to graduation date. If you have any questions regarding project timeline, please contact RISE@evms.edu.

The duration of time needed to complete your research service request will depend on the complexity of your project (for example, some projects requesting data analysis support can be completed in 2-3 months while others that need support throughout the research projects may need 12-18 months).

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 RISE@evms.edu with your service request number and the Principal Investigator's (PI) name.

For questions related to EPIC data, please contact Dr. Fang Fang at fangf@evms.edu.

For questions related to the Virginia Health Information (VHI), please contact Michael Bittner at bittnemc@evms.edu.

Date of Request:

Y-M-D

Deadline Date:

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.

Project Title:

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Principal Investigator Information

Last Name:

First Name:

Title:

Please enter your title here:

Affiliation:

Please enter your affiliation here:

Position:

Projects with EVMS students will only be accepted if the PI is their EVMS supervisor.

Supervisor/Mentor Name

Supervisor/Mentor Email

Please enter your position here:

Faculty Type:

Please enter your faculty type here:

Department:

Please enter your department here:

Phone Number:

Email:

Is this project for a graduation requirement?

Yes No

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What graduation year?

Are you the principal investigator in this study?

Yes

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Requestor Information

Last Name:

First Name:

Title:

Please enter your title here:

Affiliation:

Please enter your affiliation here:

Position:

Please enter your position here:

Is this required for graduation?

Yes No

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What year do you graduate?

Faculty Type:

Please enter your faculty type here:

Department:

Please enter your department here:

Phone Number:

Email:

Do you currently have any active service requests with RISE?

Yes

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Please list the service request numbers of all active projects you have with RISE.

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Is this a student-led project?

Yes

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1. Type of Service Request:
(Select all that apply)

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

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:
(Select all that apply)

Sentara EPIC

Sentara Cancer Registry

EVMS Allscripts

Virginia Health Information (VHI)

Other

Please Describe:

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Please Describe:

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2. Do you have IRB approval?

Yes

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Please provide IRB#:

Expiration Date:
(For full board or expedited studies only)

M-D-Y

3. Does this project have any type of funding?

Yes

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Please provide grant # and funding source:

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Please select all that apply:

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.

Provide the graduation year:

Are you seeking HADSI Pilot Funding or other internal/external grant?

If seeking grant, please provide the following:

Length of Grant, Period of Study:

Funding agency (e.g. CDC, NIH...):

Provide the deadline to submit for the grant:

4. Please attach all applicable document(s):

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 RISE 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 RISE service (contact RISE for further details).

I agree to the terms and conditions of service.

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

Signature:

Add signature

Name:

Date:

M-D-Y

For RISE Only:

Type of Project

Health Disparity Related

Yes

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Syndemic Related

Yes

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Research Core Area

Will RISE service(s) be free of charge for this project?

Yes

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Current Primary Contact: Last Name

Current Primary Contact: First Name

Primary RISE Staff Member

Secondary RISE Staff Member

Project Data Type

Non-Sentara

Sentara

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Seeking HADSI Funding

Yes

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Received HADSI Funding

Yes

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Does project have other type of funding?

Yes

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Type of funding: ______

RISE Project Number

Initial Meeting Date

M-D-Y

Project Closing Date

M-D-Y

Grant and T & E Information:

Grant Account Number

Department number

Grant type

101 Unrestricted

102 Department reserves

103 Private grants

109 Federal/State

Other

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	Title	Percentage
Primary RISE Staff
Secondary RISE Staff

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