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X4nSVPT3ZAT5fkRUsWnipwcDP2GIXYTGDG5vrqIes9xJEd79yMEgpr2DLBWAbNxU9IS8653UE7qAgou5

Consultation Request Form

Thank you for your interest in the consultation services provided by the Duke Clinical & Translational Science Institute Community Engaged Research Initiative (CERI).

This 1-hour consult is a free service provided by the Duke Clinical & Translational Science Institute's Community Engaged Research Initiative. The information you provide to CERI is confidential and will not be shared with any other entity.

Please complete the form below.

Primary Role

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Community Member

Academic Researcher/Faculty

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Are you the academic researcher?

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First Name

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Last Name

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What is the researcher's first name?

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What is the researcher's last name?

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What is the researcher's academic position within Duke?

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Please provide the name of your organization/department

E-mail

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Best Contact Number

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In addition to a consultation with CERI, are there other services or resources of interest?

Brainstorming with researchers and community to "spark" new ideas that may lead to a collaborative research project

Present elements of your research plan or design for community feedback

Apply for funding (Population Health Improvement Awards)

Request a CERI presentation for your group or department

Request community engagement education or training for your group or department

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Other

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Do you need to ask CERI for a letter of support (LOS)?

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Are you asking for a LOS from other CTSI leadership or cores (in addition to CERI)? If so, a combined letter from CTSI leadership will be provided.

Yes

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When do you anticipate you will receive notification of the award?

When do you anticipate you will start needing CERI services?

Which of CERI's community stakeholder groups would you prefer to engage with?

AME Zion HEAL - 18 trained African-American clergy health advisers

Community Consultation Studio - A convened panel of community stakeholders representing your study/program's population of interest

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If you have a specific date in mind for a CERI Presentation please include:

Topic of presentation
Expected date for presentation
Time of presentation
Location (online or in-person)
Audience (student, post doc, faculty, community organization)
Number of attendees
Additional support (Do you have AV support? Parking?)

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Study/Program Title (if applicable)

Please provide a description of your research project and consultation needs (500 words)

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Where are you in the research process?

Study Design

Funding Process

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More specifically, are you:

Brainstorming

Planning

More specifically, are you:

Applying for funding

Applied for funding

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Already funded, but have not begun the project

Implementing a funded project

Is there a time-sensitive deadline for your project?

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What is the deadline for your project?

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Does this research study/project have an IRB number?

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IRB #

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How did you hear about CERI's programs and services?

Departmental Grand Rounds

CERI Presentation

Community Event

CTSI Website

CTSI Referral

Word of mouth

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Please include the name of the community event where you heard about CERI.

Please include the name of the CTSI staff/faculty or core that referred you to CERI.

Would you like to receive our bi-monthly CERI Newsletter and occasional emails?

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Please click the link below to sign up for our bi-monthly CERI newsletter.

Community Engaged Research Initiative

If intake form was completed by a CERI staffmember, please note here:

Consultation led by:

Faculty and staff supporting consultation:

Date consult conducted:

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Please mark all Duke schools affiliated with this project:

School of Medicine

School of Nursing

Trinity College of Arts & Sciences

School of Divinity

School of Law

Fuqua School of Business

Nicholas School of the Environment

Pratt School of Engineering

Sanford School of Public Policy

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Please list any CTSI Cores collaborating on the consultation:

Recruitment Innovation Center

Special Populations

Team Science

Pilots / Accelerator

Workforce Development

Other

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Which CERI program/service/resource was recommended?

Community Consultation Studio

AME Zion HEAL Partnership

Sparks Studios

Population Health Improvement Awards

CERI Education and Training Program

CERI e-Library

N/A

Other

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What information are you hoping to gain through a CCS?

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What feedback and guidance are you seeking from our AME Zion HEAL Partners?

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What is the health topic for your Sparks Session?

What practices have already been implemented or tried? What has worked/not worked?

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Is an incentive or compensation being offered to community partners or research study participants?

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Current incentives and any CERI suggestions:

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Are there plans to return results to the communities in which you engage (if applicable)?

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Current plans and any CERI suggestions:

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CERI suggests the following referrals, approaches, resources, and/or connections:

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CERI Team's next steps - carry over action items to Smartsheet and assign person responsible.

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