Which Duke team primarily referred you to this survey?
* must provide value
DHTS/ACE/DART Heart Center Analytics/Lumedx Laboratory for Transformative Administration OASIS/PACE Services Performance Services Research Support Services Revenue Management Substrate Services Core & Research Support (SSCRS) Surgery CRU: Surgery Office of Clinical Research Surgery Data Management Other
Specify other Primary Referrer
Service Description PACE SERVICE REQUESTS For new user accounts (virtual machine), new project folders, and transfer agent/honest broker requests DATA/SAMPLE PULL Data/Sample pull and delivery from an existing Surgery database/registry/bio-repository or from Epic/MaestroCare data source DATA VISUALIZATION Create a data report or visualization tool/dashboard from an existing data set DATABASE/SURVEY BUILD Build a new database with no long-term support or data management (includes eConsent builds) DATABASE REVISIONS Re-structure and revise an existing database DATABASE AND DATA MANUAL CREATION Build a database; work with the investigator and data enterer to develop a data reference manual with standard definitions and guidance for data entry consistency FULL DATA PROJECT SUPPORT Build a database; develop and maintain data reference manual; provide reporting and overall data management for the project lifetime; collaborate with stats, etc. DATA PROJECT MANAGEMENT For assistance with data use agreements, data transfer agreements, IRB facilitation, process improvement, etc. STUDY PLANNING/DATA CONSULTATION For expert guidance tailored to clinical data management needs, including study planning, regulatory compliance, budget considerations, and data management strategy optimization to achieve your research goals efficiently.
Which main service or level of support most closely matches your request?
* must provide value
PACE SERVICE REQUESTS
DATA/SAMPLE PULL
DATA VISUALIZATION
DATABASE/SURVEY BUILD
DATABASE REVISIONS
DATABASE AND DATA MANUAL CREATION
FULL DATA PROJECT SUPPORT
DATA PROJECT MANAGEMENT
PACE/DEDUCE/OTHER DATA TRAINING: For training on the various databases/tools used at Duke
STUDY PLANNING/CONSULTATION
PACE SERVICE REQUESTS
DATA/SAMPLE PULL
DATA VISUALIZATION
DATABASE/SURVEY BUILD
DATABASE REVISIONS
DATABASE AND DATA MANUAL CREATION
FULL DATA PROJECT SUPPORT
DATA PROJECT MANAGEMENT
PACE/DEDUCE/OTHER DATA TRAINING: For training on the various databases/tools used at Duke
STUDY PLANNING/CONSULTATION
Is this an eConsent survey?
* must provide value
Yes No
Is there a Regulatory Coordinator assigned to this project?
* must provide value
Yes No
What is the Regulatory Coordinator's email address?
From which project is data being requested?
Abdominal Transplant Repository/Registry
Advanced Heart Failure: VAD and Heart Transplant Data Repository
Benign Esophageal Database
Department M&M Database
Duke Breast Database: DB2
Duke Pancreatic Surgery Database
ECMO Database
Emergency General Surgery Database: EGS
Lung Transplant Database
NSQIP
Perioperative Optimization of Senior Health (POSH) Database
SOCR Clinical Trial Enrollment Data
Surgery Bio-Repository/1000 Patient Project
Surgical Critical Care Initiative: Tissue and Data Acquisition Protocol
Valve Repair and Replacement Database
Vizient
Other/Epic or MaestroCare
Abdominal Transplant Repository/Registry
Advanced Heart Failure: VAD and Heart Transplant Data Repository
Benign Esophageal Database
Department M&M Database
Duke Breast Database: DB2
Duke Pancreatic Surgery Database
ECMO Database
Emergency General Surgery Database: EGS
Lung Transplant Database
NSQIP
Perioperative Optimization of Senior Health (POSH) Database
SOCR Clinical Trial Enrollment Data
Surgery Bio-Repository/1000 Patient Project
Surgical Critical Care Initiative: Tissue and Data Acquisition Protocol
Valve Repair and Replacement Database
Vizient
Other/Epic or MaestroCare
Indicate which DATA/SAMPLE TYPES you would like to utilize.
* must provide value
Clinical Data Only
Blood, Tissue, and/or Other Biospecimens Only
Clinical Data Associated with Biospecimens
Clinical Data Only
Blood, Tissue, and/or Other Biospecimens Only
Clinical Data Associated with Biospecimens
Fully De-identified Data
Identifiable Data (Any Protected Health Information)
Fully De-identified Data
Identifiable Data (Any Protected Health Information)
What type(s) of samples are you requesting?
Describe the exact number and volume of samples needed.
What assays are you planning to run on the samples?
If data/samples are obtained from the Department of Surgery Bio-Repository Team, I agree to:
1. Report any results and outcomes back to the Bio-Repository team
2. Acknowledge the use of the Department of Surgery Bio-Repository services and include major contributing key
personnel as co-authors with adequate contributions to any publication as a result of this work
* must provide value
Name of Person Completing Survey
* must provide value
Last Name, First Name
Survey Respondent Duke Surgery Position
* must provide value
Resident/Fellow
Faculty
Staff
Other
Resident/Fellow
Faculty
Staff
Other
Choose One
Other Duke Surgery Position
E-Mail to Contact for Project Start-Up
* must provide value
Person Responsible for Working with Data Team during Project Start-Up
* must provide value
Last Name, First Name
Duke Faculty Member Leading Project
If different than person completing this survey
Last Name, First Name
Associated Surgical Department
* must provide value
Department of Surgery Department of Emergency Medicine Department of Urology Other/Non-Surgery
Abdominal Transplant Cardiovascular and Thoracic Emergency Medicine Head and Neck & Communication Sciences Metabolic and Weight Loss Pediatrics Plastic, Maxillofacial, and Oral Surgical Sciences Surgical Oncology (AOGI) Trauma and Critical Care Urology Vascular and Endovascular Laboratory for Transformative Administration (LTA) N/A: Department-Wide Other/Non-Surgery
Choose one
Surgery Division
* must provide value
Abdominal Transplant Cardiovascular and Thoracic Metabolic and Weight Loss Minimally Invasive Surgery (MIS) Pediatrics Plastic, Maxillofacial, and Oral Surgical Sciences Surgical Oncology (AOGI) Trauma and Critical Care Urology Vascular and Endovascular
Head & Neck Division
* must provide value
Communication Sciences Facial Plastic and Reconstructive Surgery Head and Neck Surgical Oncology Laryngology Pediatric Otolaryngology Rhinology and Skull Base Surgery
Laboratory for Transformative Administration (LTA) N/A: Department-Wide Other/Non-Surgery
Other/Non-Surgery Support Area Name
Project Title
* must provide value
Project Type
* must provide value
Research/Non-Exempt
Quality Improvement/Exempt
Operational/Administrative
Unsure
Research/Non-Exempt
Quality Improvement/Exempt
Operational/Administrative
Unsure
Choose one
Are you intending to publish data from this project and/or present information external to Duke?
* must provide value
Yes No
Is the Project IRB Approved?
* must provide value
Yes No Not Applicable
What is the protocol IRB number?
Pro followed by 8 digits
Is IRB Support Needed?
* must provide value
Yes No Not Applicable
Is this a Multi-Site Project?
* must provide value
Yes No
Is there funding available to support this request?
* must provide value
Yes No
What is the main funding type?
* must provide value
Departmental
Divisional
Industry
Grant
Other
Departmental
Divisional
Industry
Grant
Other
What other type of funding?
Specify Fund Code if Known
Are you requesting a new PACE virtual machine?
* must provide value
Yes No
How many new PACE accounts/virtual machines are you requesting?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Faculty/Staff Student
Are you requesting a new PACE project folder?
* must provide value
Yes No
Are you requesting an honest broker data export?
* must provide value
Yes No
Names of Files/Folders to be Transferred (files must be saved to your PACE Outbox in order for the Honest Broker to have access for review and export)
Explain the reason for the data export and what type of data will be included in the file(s).
Summary of Request/Scope of Work
Include intent of data request if applicable: publication, grant submission, etc.
* must provide value
Upload any Relevant Accompanying Materials to Assist with Scope of Work
Is a statistical analysis being performed under this project?
* must provide value
Yes No
Who is performing the analysis?
* must provide value
Duke Biostatistician/Methodologist
Study Team Member
Non-Duke Biostatistician/Methodologist
Other
Duke Biostatistician/Methodologist
Study Team Member
Non-Duke Biostatistician/Methodologist
Other
Name of Statistician/Methodologist
Preferred Project Completion Date
Note: Timeline for initial consultation is roughly 2 weeks. Timeline for project completion is dependent upon faculty/trainee/staff engagement, funding availability, and existing work load.
* must provide value
Today M-D-Y mm/dd/yyyy
Estimated Duration of the Project
Please specify how long you expect the project/study to be active
* must provide value
i.e., 6 months, 3 years, etc.
This REDCap project was developed by the Department of Surgery Data Management Team. Please do not copy or share the project build without contacting the Surgery Data Management Team at SurgeryData@duke.edu .