Research Service Annual Review Form
Louis Stokes DVA Medical Center

Form Directions: This form is protected (limited access to fill-in fields). Use the tab key or mouse to navigate the fill-in fields. Formatting is limited to text only (no bulleted lists, numbering, etc). In the event that you are unable to navigate through this document or would like to format it or add additional information, you may disable the protected features by clicking on the Review Tab, clicking “Restrict Editing”, and “Stop Protection”.

1.Principal Investigator Name:

2.Project Title:

3.Is this a final report for this project?

Yes (If “Yes,” go to Item 3A)

No (If “No,” go to Item 3B and 3C)

3A.Please provide a brief summary of the findings associated with this project (There is a 200 word limit for responses. DO NOT INCLUDE TABLES, DO NOT UNDERLINE, USE SUBSCRIPTS, SUPERSCRIPTS, OR SYMBOLS. DO NOT submit copies of articles.

3B.Please describe the progress made on this project in the past year(There is a 200 word limit for responses. DO NOT INCLUDE TABLES, DO NOT UNDERLINE, USE SUBSCRIPTS, SUPERSCRIPTS, OR SYMBOLS. DO NOT submit copies of articles.):

3C.Please list the current personnel working on this project and provide complete Conflict of Interest Statements for each Principal Investigator, Co-Principal Investigator, Co-Investigator, (faxed or email Conflict of Interest Statements are acceptable).

Name / Role

4.Has this project resulted in any journal articles that have been published or accepted for publication?

Yes (If “Yes,” go to Item 4A)

No (If “No,” go to Item 5)

4A. List these publications:

5.Has this project resulted in any conference papers that have been presented or accepted?

Yes (If “Yes,” go to Item 5A)

No (If “No,” go to Item 6)

(If “Yes,” to Item 5)5A. List these conference papers:

6.Describe any impediments to the progress of this project and your recommended solutions:(Note that any impediments to the progress of your project will be kept confidential.)

7.Does this project involve the collection individually identifiable information as it relates humans?

Yes (If “Yes,” go to Item 8)

No (If “No,” your Annual Review is complete)

8.Does this project involve the collection of any of the following information as it relates to individual, human, research participants?

Yes

/

No

  1. Names or initials

  1. Geographic subdivisions smaller than a state

  1. Any elements of dates except the year and all ages over 85

  1. Telephone numbers

  1. Fax numbers

  1. E-mail addresses

  1. Social Security Numbers (fragments or scrambled)

  1. Medical record numbers

  1. Health plan beneficiary numbers

  1. Account numbers

  1. Any certificate or license numbers

  1. Vehicle identifiers and license plate numbers

  1. Device identifiers and serial numbers

  1. Websites

  1. IP addresses

  1. Biometric identifiers, including finger and voice prints

  1. Full-face photographs and any comparable images

  1. Any other unique identifying number, characteristic or code

(If “Yes” to Item 8R),describe these identifiers:

If the answer to anyof the information types listed in Items8A through 8Ris, “Yes” go to Item 9 and contact Holly Henry (email: phone 216 791-3800 x4657).

If the answer to all of the information types listed in Items 8A through 8R are,“No” this portion of theR&D Committee Annual Review is complete.

Yes

/

No

9.Are all hardcopies of the information described in Item 8 used and stored within the LSCDVAMC?
10.Are all electronic copies of the information described in Item 8 used and stored within the LSCDVAMC?
11.Are all of the electronic versions of the information described in Item 8 on network accessible media behind the VA Firewall?

If the answer toall of the Items 9, 10, and 11 is, “Yes” your AnnualReview is complete.

If the answer to any of the Items 9, 10, and 11is, “No”:

  • Contact the LSCDVAMC Security Officer Robert Hall () to discuss your data storage and security plans

R&D #:
(Assigned by Research Office)

Title of Project:

FOR RESEARCH OFFICE USE ONLY

Does the information provided adequately address the amount of progress made on this project over the last year?
Yes
No(Please indicate the shortcomings of this project report under “Comments”)
Comments:
As a reviewer, are you an investigator, consultant, collaborator, or study personnel on the proposed study; do you have a financial interest in the study; or do you have any other conflict of interest with this study?
Yes** No
**If yes, please do not perform this review and contact the Research and Development Committee Coordinator,ChristinaBennett (email: )
Signature of R&D Committee Member
Name: / Date

R&D Committee Annual Review Form(Revised 12/29/2017) – Page 1 of 4