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kbMLi3Nczs8EmVURC35WfiufuIxcci6ARQucWIbfR

MRP PAC Patient Engagement Studio Submission Form

Please complete the application form below.

Thank you!

myRESEARCHpartners Patient Advisory Council Patient Engagement Studio Submission Form

Thank you for your interest in a consultation with the MyResearchPartners Patient Advisory Council. Please tell us a little bit about your project.

What's your net ID or Duke Unique ID?

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First Name

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Last Name

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Your email address

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What's the best number to reach you?

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How do you prefer to be contacted?

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phone

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School, Center or Institute

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Specify other

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Academic Department

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What Anesthesiology Division are you with?

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What Community Family Medicine division are you with?

What Dermatology division are you with?

What Medicine division are you with?

What Neurology division are you with?

What Neurosurgery division are you with?

What Obstetrics and Gynecology division are you with?

What Ophthalmology division are you with?

What Orthopaedic Surgery division are you with?

What Pathology division are you with?

What Pediatrics division are you with?

What Psychiatry and Behavioral Medicine division are you with?

What Radiology division are you with?

What Surgery division are you with?

What is your current appointment?

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If you are a student (graduate or undergraduate), who is your faculty mentor?

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How long have you been at Duke?

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OUR COMMITMENT TO YOU

Confidentiality of Work Product:

The Council provides feedback and guidance to researchers conducting innovative research projects. As such, it is imperative that researchers who share ideas and proposals with Council staff and members are confident that their proposals and project ideas will be kept confidential and only disclosed to the extent necessary to provide consultation to the investigator. It is understood that investigators may submit confidential information to the Council including but not limited to proposals and application materials, regardless of whether such information is designated as confidential information at the time of its disclosure. All proposals and application materials shared with the Council will be kept confidential and not disclosed to anyone except to the extent necessary to evaluate the proposal or provide the requested consultation or services associated with the proposal. Each Council member has acknowledged that they will maintain the confidentiality of the proposal information and associated materials consistent with this policy.

What is the title of your project?

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What is the funding source for your project (or what funds will you be seeking)?

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NIH / Federal

PCORI

Foundation

Industry

Internal

Other

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Please describe internal or other source of funding

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Your Research: in 200 words or less and in lay-friendly terms, please describe your overall program of research and how you came to be involved in this area of research.

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Your Focus: in 200 words or less and in lay-friendly terms, please describe what problem(s) you seek to address in this research study

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Key Terms and Definitions: in lay-friendly terms, please describe any key terms and definitions for this research effort.

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Your Methods: in 200 words or less and in lay-friendly terms, please describe your study methods.

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Participants: what types of study participants are you seeking (i.e., your key eligibility criteria)?

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Community: in what community areas is/will your study be implemented?

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Partners: have you identified any community or patient partners for collaboration on this project?

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Yes

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If yes, please list and describe.

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If no, are you looking for community or patient partners as collaborators?

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Yes

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If yes, please describe what you're looking for in a community or patient collaborator.

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What are the anticipated benefits of your research to the patient population or community?

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Please list your specific questions for the Council.

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In return for consultation and feedback from the Council, we ask all investigators and study teams to commit to providing at least annual updates on the progress of their project back to the Council and to commit to sharing aggregate results of the study with study participants. Please indicate whether you can adhere to this expectation.

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Yes

I'm not sure

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Please add your signature as attestation of your commitment to providing updates and aggregate study results.

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Add signature

Please explain why you believe you cannot commit to providing updates to the Council and aggregate study results to study participants.

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