Preliminary Study Proposal Form
PROPOSAL INFORMATION☐ / Investigator Initiated Study / ☐ / Non-Research Project
☐ / Industry Sponsored Clinical Trial / ☐ / NCORP
Project Title:
Proposed Principal Investigator:
Is this request part of an existing project or program at Essentia Health?
☐ / Yes – Ifyes, which one?
☐ / No
PROPOSAL SUMMARY
Please provide a summary of the project including impact on clinical careat Essentia Health (250 words or less).
FUNDING SOURCE
Please indicate your plan for funding the proposal. NOTE:Obtaining full funding for a project is the responsibility of the Principal Investigator/Project Director. Nominal start-up support may be provided subject to the approval of the EIRH Executive Director.
☐ / Submission to external funding agency
☐ / Submission to EH foundation
☐ / Departmental Budget –Indicate Department Name: Company #: Cost Center #:
NOTE:Departmental funds require approval by your market CFO (East-Kevin Boren, West-Kyle Dorow, Central-David Pilot) and your SVP Operations. Once total costs are determined, EIRH with generate a form for approval routing. Form will include total dollar amount, timeline and department to be charged.
☐ / Industry Funded Clinical Trial – (such as pharmaceuticals, devices, etc)
☐ / NCORP Clinical Trial
☐ / Other Clinical Trial with existing funding (such as NIH or PCORI)
☐ / Other (briefly explain):
ONE MISSION, ONE ESSENTIA
Which parts of the Essentia Aspirational Aims are addressed by this proposal? (select all that apply):
☐ / Engaged and Inspired People
☐ / Zero Preventable Harm
☐ / Achieve Health and Vitality with our Communities
ESSENTIA INVOLVEMENT
Does the proposal include any of the following resources or strategic areas? (If checked, proposal may require additional review/approvals)
☐ / Proposed Essentia-wide initiative (including surveys with participants selected from general Essentia patient population)
☐ / Involvement of Primary Care
☐ / Substantive involvement (beyond routine activities) of more than one Essentia department with new coordination required between departments
IRB OF RECORD
Will this project be reviewed by the Essentia Health IRB?
☐ / Yes
☐ / No - If no, which IRB?
PRINCIPAL INVESTIGATOR SIGNATURE
Signature: / Printed Name: / Date:
ESSENTIA INSTITUTE OF RURAL HEALTH ADMINISTRATIVE REVIEW
☐ / Approved
☐ / Denied
Comments:
Date Reviewed: / Signature:
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COMBINED Ver 506-30-2017
Email completed forms and/or questions to
(Found in your Essentia Health Outlook Address Book as “EIRH Proposals”)
Page 1 of 2
COMBINED Ver 506-30-2017