(This is not included on the final version of the survey)
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
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.
Y-M-D
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.
Principal Investigator Information
MD PhD MD, PhD DO Master's Other
Please enter your title here:
EVMS Sentara Other
Please enter your affiliation here:
Faculty Fellow Resident Staff Student Other
Please include your Supervisor/Mentor's Name:
Supervisors or mentors are required to attend all initial meetings with PI and RISE.
Projects with EVMS students will only be accepted if the PI is their EVMS supervisor.
Please enter your position here:
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:
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:
Please provide your institution (e.g. @evms.edu) email address.
Is this project for a graduation requirement?
Yes No
Are you the principal investigator in this study?
Yes
No
MD PhD MD, PhD DO Master's Other
Please enter your title here:
EVMS Sentara Other
Please enter your affiliation here:
Faculty Fellow Resident Staff Student Other
Please enter your position here:
Is this required for graduation?
Yes No
What year do you graduate?
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:
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:
Please provide your institution (e.g. @evms.edu) email address.
Do you currently have any active service requests with RISE?
Yes
No
Please list the service request numbers of all active projects you have with RISE.
Service request numbers are typically in the SRXXXX (Last Name, First Name) before 07/01/23, or in the YYYY-XXX format starting after 07/01/23. The service request numbers are provided via email when the project was assigned.
Are learners (students, residents, or fellow) involved in this project?
Yes
No
1. Type of Service Request:
(Select all that apply)
*IRB approval is required. **Grant submission requires 3 months notice.
Please provide any other relevant information about your project and/or points to consider for assigning your project to a RISE team member.
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)
Data extraction from EPIC will require more than 3 months.
2. Do you have IRB approval?
Yes
No
Expiration Date:
(For full board or expedited studies only)
M-D-Y
3. Does this project have any type of funding?
Yes
No
Please provide grant # and funding source:
Please select all that apply:
Provide the graduation year:
Are you seeking HADSI Pilot Funding or other internal/external grant?
HADSI Pilot Funding Other 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):
*If no protocol has been drafted, RISE requires that investigators still provide a document describing the project.
Attach Protocol (Draft or Final) Here
* must provide value
Attach IRB Approval Letter Here
Attach List of Variables Here
Attach Existing Data Here
Please do not upload data with PHI
Attach Sample of Questionnaire Here
If more than one publication, please check 'Other documents related to this project.'
How many other documents do you need to submit?
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
Attach Other Document Here
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 or currently seeking funding, including RISE personnel into the project budget will be discussed during the initial consultation meeting. (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.
M-D-Y
Current Primary Contact: Last Name
Current PI or primary person responsible for project
Current Primary Contact: First Name
Primary RISE 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 Miasha O'Neal
Secondary RISE 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 Miasha O'Neal
YYYY-XXX
Will RISE service(s) be free of charge for this project?
Yes
No
Yes
No
(Did they submit a LOI?)
Yes
No
(Project selected for HADSI Funding)
Today M-D-Y
Today M-D-Y The date when the project was closed.
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
Non-Sentara
Sentara
Will RISE help provide the data?
Yes (data extraction or survey development)
No (PI team provided the data)
Are there learners in the research team?
Does project have other type of funding?
Yes
No
Grant and T & E Information:
Start Date End Date Budget Project
M-D-Y
M-D-Y
M-D-Y
M-D-Y
101 Unrestricted
102 Department reserves
103 Private grants
109 Federal/State
Other
Number of RISE staff on the project
RISE Staff Name Title Percentage 1 2
PI
Co-PI
Co-I
I
Other
Secondary RISE Staff Title
PI
Co-PI
Co-I
I
Other
Primary RISE Staff Percentage
%
Secondary RISE Staff Percentage
%
Staff Name Staff Percentage 3 4 5 6 7
%
%
%
%
%