Primary Role
* must provide value
Community Member
Academic Researcher/Faculty
Other
Are you the academic researcher?
Yes No
First Name
* must provide value
Last Name
* must provide value
What is the researcher's first name?
* must provide value
What is the researcher's last name?
* must provide value
What is the researcher's academic position within Duke?
* must provide value
Undergraduate student Graduate student Post-doctoral fellow Adjunct Faculty Associate Professor Assistant Professor Full Professor Other
Please provide the name of your organization/department
E-mail
* must provide value
Best Contact Number
* must provide value
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
N/A
Other
Check all that apply
Do you need to ask CERI for a letter of support (LOS)?
Yes
No
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
No
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
Upload your draft letter of support
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?)
Study/Program Title (if applicable)
Please provide a description of your research project and consultation needs (500 words)
Where are you in the research process?
Study Design
Funding Process
Implementation
N/A
Other
Check all that apply
More specifically, are you:
Brainstorming
Planning
Check all that apply
More specifically, are you:
Applying for funding
Applied for funding
Reapplying for funding
Check all that apply
More specifically, are you:
Already funded, but have not begun the project
Implementing a funded project
Check all that apply
Is there a time-sensitive deadline for your project?
Yes No N/A
What is the deadline for your project?
Today M-D-Y
Does this research study/project have an IRB number?
Yes No N/A
Upload any files that provide additional background information to assist us with answering your questions
How did you hear about CERI's programs and services?
Departmental Grand Rounds
CERI Presentation
Community Event
CTSI Website
CTSI Referral
Word of mouth
N/A
Other
Check all that apply
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?
Yes, sign me up No thank you
If intake form was completed by a CERI staffmember, please note here:
Faculty and staff supporting consultation:
Today M-D-Y
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
Other
Check all that apply
Please list any CTSI Cores collaborating on the consultation:
Recruitment Innovation Center
Special Populations
Team Science
Pilots / Accelerator
Workforce Development
Other
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
Check all that apply
What information are you hoping to gain through a CCS?
What feedback and guidance are you seeking from our AME Zion HEAL Partners?
What is the health topic for your Sparks Session?
What practices have already been implemented or tried? What has worked/not worked?
Is an incentive or compensation being offered to community partners or research study participants?
Yes, No N/A
Current incentives and any CERI suggestions:
Are there plans to return results to the communities in which you engage (if applicable)?
Yes No N/A
Current plans and any CERI suggestions:
CERI suggests the following referrals, approaches, resources, and/or connections:
CERI Team's next steps - carry over action items to Smartsheet and assign person responsible.