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Submission Date: MM/DD/YYYY / Approval Date:
MM/DD/YYYY

Project Submission Form

SECTION A (Complete for every project):

Submit request to Suzanne Gillespie (email: ;phone: (503) 528-3977)
I. STUDY TITLE
II. PROPOSING INVESTIGATOR / Name:
Institution:
Mailing Address:
Email Address:
Phone:
III. BACKGROUND AND RATIONALE
IV. SPECIFIC AIMS AND HYPOTHESES
V. STUDY POPULATION / Inclusion Criteria:
Exclusion Criteria:
VI. DESCRIPTION OF REQUESTED CHARN DATA AND USE
VII. PLANNED STARTING / CONCLUSION DATES
VIII. CLINICAL SIGNIFICANCE
IX. COMMUNITY RELEVANCE
X. FEASIBILITY
XI: ADDITIONAL CONSIDERATIONS (include dissemination)

Please select the desired outcomes for this work (check all that apply):

Proposal for External Funding (Complete Section B)
Internal Project (Complete Section C)
Manuscript, Poster and/or Presentation (Complete Section D)
Prep to Research (Complete Section E)
Data Analysis Request (Complete Data analysis request form – Appendix I)

SECTION B: Fill out this form prior to obtaining approvals for external funding.

External funding proposals for The Community Health Applied Research Network (CHARN) may be submitted by any member of the network, and/or other participating organizations in collaboration with CHARN. All final materials must be submitted to Suzanne Gillespie ()and approved by the Research Planning & Publications subcommittee.

I. TARGET FUNDING AGENCY
II. TARGET FUNDING ANNOUNCEMENT
III. SUBMISSION DEADLINE
IV. STUDY DESIGN AND STATISTICAL ANALYSIS PLAN
V. DETAILED BUDGET
VI. HOW WILL THIS PROJECT SUPPORT CHARN SUSTAINABILITY?

Approved by CHARN Research Planning & Publications Subcommittee: 

Approved by CHARN DCC Principal Investigator: 

SECTION C: Fill out this form prior to obtaining approvals for an internal project (new working group).

I. SELECT COLLABORATING NODES & CHCs / AAPCHO
Asian Health Services
Waianae Coast Comprehensive Health Center
Charles B. Wang Community Health Center
Waimanalo Health Center
Alliance
PCC Community Wellness Center
Erie Family Health Center
Howard Brown Health Center
Heartland Health Outreach
Near North
North Country Healthcare
Fenway
Fenway Health
Chase Brexton Health Services
Beaufort Jasper Hampton Comprehensive Health Services
OCHIN
Virginia Garcia Memorial Health Center
Open Door Community Health Center
Multnomah County Health Department
OHSU Richmond Clinic
II. CO-INVESTIGATORS / WORKING GROUP MEMBERS

Approved by CHARN Research Planning & Publications Subcommittee: 

Approved by CHARN DCC Principal Investigator: 

SECTION D: Fill out this form prior to obtaining approvals for manuscript, poster and/or presentation development.

Peer reviewed papers, posters or presentations related to The Community Health Applied Research Network (CHARN) may be submitted by any member of the network, and/or other participating organizations in collaboration with CHARN. All final materials must be submitted to Suzanne Gillespie ()and approved by the Research Planning & Publications subcommittee. All manuscripts and presentations emerging from CHARN must acknowledge our funder (see below for details) and institutions involved in the study.

I. PROPOSED TITLE OF MANUSCRIPT, POSTER AND/OR PRESENTATION
II. TARGETED JOURNAL, SOCIETY OR MEETING FOR SUBMISSION
III. ESTIMATED SUBMISSION DATE:
IV. NAME OF FIRST AUTHOR:
V. NAME OF CO-AUTHORS* / AAPCHO Co-Author(s):
Alliance Co-Author(s):
Fenway Co-Author(s):
OCHIN Co-Author(s):
DCC Co-Author(s):
HRSA Co-Author(s):
CHARN External Co-Author(s):

* There must be authorship representation from each Node where Nodal data is involved.

Funding Sources (all publications must include the following language in acknowledging funding for CHARN): Funding for CHARN was provided by the Health Resources and Services Administration (HRSA); CHARN1: Grant # UB3HA20236, CHARN2: Contract # HHSH250201400001C. In addition, each manuscript must include the currently approved CHARN acknowledgment.

Approved by CHARN Research Planning & Publications Subcommittee: 

Approved by CHARN DCC Principal Investigator: 

SECTION E: Fill out this form prior to obtaining approvals for Prep-to-Research Request.

The HIPAA Privacy Rule designates as “preparatory to research ” the following activities:

1) The development of research questions;

2) The determination of study feasibility (in terms of the available number and eligibility of potential study participants);

3) The development of eligibility (inclusion and exclusion) criteria; and

4) The determination of eligibility for study participation of individual potential subjects.

It is important to note that being able to proceed with prep-to-research work will increase the CHARN Network’s efficiency and allow progress to be made within the working group while awaiting IRB approval.

In order to access the CHARN data warehouse for preparatory to researchpurposes, the following two representations must be TRUE. Place an "X" inside the box to indicate that the statement is true.

TRUE _____The use or disclosure is solely to review data warehouse data as necessary to prepare a research proposal / protocol, or for similar purposes preparatory to research.

TRUE _____The data warehouse data that is being used is the minimum necessary for research preparation purposes.

My submission of this form indicates that all of the information is accurate and that I will comply with CHARN policies and federal privacy regulations.

Add data definition: Complete Data Request Form with submissions.

Approved by CHARN Research Planning & Publications Subcommittee: 

Approved by CHARN DCC Principal Investigator: 

APPENDIX I: DATA ANALYSIS REQUEST FORM

(A new form needs to be completed for each data analysis request)

Data Request Form

Submit to DCC by emailing request to

Request Date / ____/____/______
Request Source /

Writing group: (paper #) ______

Working group (workgroup name): ______

HRSA

External request (organization name): ______

Requester / Name: ______
Email: ______
Phone: ______
Abstract / Yes, indicate abstract submission due date: ____/____/______
No
Population / Describe your population for this request (e.g., all CHARN data warehouse patients with type I diabetes as defined below)
Summary / Provide a summary of this request (e.g., create table for population defined above by node with the following demographics – gender, age at time of data warehouse inclusion – see mock-up table attached)
Description / Provide a description of needed ICD9 codes, procedures, medications, labs and other relevant cohort information in order to define the population, produce table or run analysis (e.g., ICD9: Two distinct visits with any of the following ICD-9 codes : 250.01, 250.11…)
Date range / Describe date range for this request (e.g., all years in data warehouse or 2008 only)

Use the CHARN data dictionary to list the tables and fields needed for this request. This may be done with help from the DCC lead analyst. Indicate tables across row one and associated fields underneath each table name (see example in column one).

Table name: / Table name: / Table name: / Table name: / Table name: / Table name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:
Field name: / Field name: / Field name: / Field name: / Field name: / Field name:

New variables/calculations:

Variable / Calculation

Table mock-up attached

CHARN Project Submission Form4/6/2015Page | 1