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/^((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$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

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/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

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/^\d{3}-\d\d-\d{4}$/

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/^[0-9]{4,9}$/

/^\d{5}-\d{4}$/

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

QvySV7PNR6cbIySZzaYFh5J2kbVzKZp7BWK6vGobFwWCJD6E2vTuS5YQDyxf5ds4aNpLWvMrIMCq82WvykCansdbAFzgmSnuQHhJ7DERfRZLjaes2ZP

HADSI Service Request Form

EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI)
Service Request Form

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

The duration of time needed to complete your research service request will depend on the complexity of your project (for example, so service requests can be completed in 2-3 months while others 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 HADSI@EVMS.EDU with your service request number and requestor name.

Date of Request:

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Y-M-D

Deadline Date:

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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.

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Principal Investigator Information

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Is this project for a graduation requirement?

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What graduation year?

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Are you the principal investigator in this study?

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Requestor Information

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Is this required for graduation?

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Do you currently have any active service requests with HADSI?

Yes

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

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Is this a student-led project?

Yes

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

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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

To request grant writing services, please fill out the form located below:

Attach the completed form to this request.

**Grant writing servics must be submitted at least 3 months prior.

Attachment:

Grant Writing Assistance Form.docx

Data Source:
(Select all that apply)

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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?

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Yes

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Please provide IRB#:

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

M-D-Y

3. Does this project have any type of funding?

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Yes

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Please provide grant # and funding source:

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Please select all that apply:

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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:

Length of Grant, Period of Study:

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

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4. Please attach all applicable document(s):

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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).

I agree to the terms and conditions of service.

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

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Date:

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For HADSI Only:

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

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Current Primary Contact: Last Name

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Primary HADSI Staff Member

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Project Data Type

Non-Sentara

Sentara

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HADSI Funded Project

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Does project have other type of funding?

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Yes

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Type of funding: ______

Service Request Number

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HADSI Service Request Form

EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI)Service Request Form

Principal Investigator Information

Requestor Information

Terms and Conditions

For HADSI Only:

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EVMS-Sentara Healthcare Analytics and Delivery Science Institute (HADSI)
Service Request Form