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PCORnet NETWORK COLLABORATOR REQUEST

Please complete this form if you are interested in connecting with one or more PCORnet Collaborative Research Groups (CRGs), Clinical Data Research Networks (CDRNs), and/or Patient Powered Research Networks (PPRNs) to obtain scientific, investigator and/or patient/participant expertise. Please contact the PCORnet Front Door if you have any questions .

# / Question / Response
1 / Request Date
Principal Investigator / Requester Information
2 / First Name
3 / Last Name
4 / Title
5 / Requesting Institution / Organization
6 / Email Address
7 / Phone Number
8 / Mailing Address
9 / City
10 / State
11 / Zip Code
12 / Would you like to provide a second contact for correspondence? / ☐Yes
☐No
If yes, please provide email address
13 / Does this request originate from a PCORnet CDRN (Clinical Data Research Network) or PPRN (Patient Powered Research Network)? / ☐No
☐Yes, CDRN
☐Yes, PPRN
If Yes, this request originates from a CDRN, select the CDRN. / ☐ ADVANCE
☐CAPriCORN
☐GPC
☐ LHSNet
☐Mid-South
☐ NYC
☐OneFlorida
☐ PaTH
☐PEDSnet
☐PORTAL
☐pSCANNER
☐REACHnet
☐SCILHS
If Yes, this request originates from a PPRN, select the PPRN. / ☐ABOUT
☐AR-PoWER
☐CCFA
☐CENA
☐Community and Patient-Partnered Centers of Excellence forBehavioral Health
☐COPD
☐DuchenneConnect
☐Health eHeart Alliance
☐ImproveCareNow
☐Interactive Autism Network
☐Mood
☐Multiple Sclerosis
☐National Alzheimer’s and Dementia Patient and Caregiver-Powered Research Network
☐NephCure Kidney Network
☐PARTNERS
☐Phelan-McDermid Syndrome Data Network
☐PI-CONNECT
☐PRIDEnet
☐Rare Epilepsy Network
☐Vasculitis
14 / Is this request from a PCORnet Collaborative Research Group (CRG)? / ☐Yes
☐No
If yes, select CRG / ☐Cardiovascular Health
☐ Pediatrics
☐ Health Disparities
☐Other, define:
15 / Is this request from the PCORnet Coordinating Center request? / ☐Yes
☐No
Collaboration Request
16 / Select the type(s) of Network collaboration you are seeking. / ☐Clinical Data Research Network (CDRN)
☐Patient Powered Research Network (PPRN)
☐Collaborative Research Group (CRG)
17 / Select the areas you are seeking collaboration.
/ ☐Feasibility, Provide Detail:
☐CDM data request, Provide Detail:
☐Participant/Patient recruitment/enrollment, Provide Detail:
☐Participant/Patient engagement, Provide Detail:
☐Investigator expertise Provide Detail:
☐Participant/Patient expertise, Provide Detail:
☐Other, Specify:
18 / Will you be requesting data from the collaborating Network?(If data is being requested through PCORnet, the collaborator must meet current PCORnet standards for data use.) / ☐Yes
☐No
If yes, what type of data? / ☐ De-identified (aggregate)
☐Limited data set
☐ PHI with consent
19 / What stage is this project? (e.g., protocol development, implementation, recruiting)
20 / Describe the time period you are seeking collaboration? / ☐<1 month
☐1-3 months
☐3-6 months
☐>6 months
☐ Other, Specify:
Project Information
21 / Research Project Title
22 / Type of Study
Intervention Trials, which usually involve randomization at the participant/patient, physician, clinic, hospital, or systems levels, but could use non-random allocation of the intervention.
Retrospective Observational Studies that use existing data in cross-sectional or longitudinal analyses.
Prospective Observational Studies that involve collection of new data. / ☐Intervention Trial
☐Retrospective Observational Study
☐Prospective Observational Study
☐Other study type, describe:
23 / Area(s) being studied / ☐Pediatrics
☐Cardiovascular
☐ Health Disparities
☐Cancer
☐Behavioral Health
☐Gastroenterology
☐ Autoimmune
☐Neurosciences
☐Pulmonary
☐Healthcare Delivery
☐Obesity/Diabetes
☐ Renal
☐Rare Diseases, Specify:
☐ Other, Specify:
24 / Describe study population
25 / Describe the Primary Aims or research questions to be addressed
26 / Describe the Secondary Aims or research questions to be addressed
27 / Are you planning an interventional treatment that is assigned by the study team; not chosen by the provider/participant/patient? / ☐Yes
☐No
If Yes, what type? / ☐Drug
☐Medical Device
☐Behavioral
☐Other, specify
28 / Describe the intervention(s).
Funding
29 / Have you already obtained funding? / ☐Yes
☐No
If yes, who will be funding this study? / ☐PCORI
☐NIH
☐Industry
☐Foundation
☐Other, Describe funding source:
If no, describe when and where you will seek funding.
30 / Is there anything else you would like to share about your request?
31 / I understand that this information will be distributed to PCORnet Clinical Data Research Networks (CDRNs), Patient Powered Research Networks (PPRNs), and applicable Collaborative Research Groups (CRGs) to communicate opportunities for collaboration. / ☐Yes
☐No

V. 9/26/2016