The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

EnaBCv8ore92d7TyTVjkZtu6ZpyDFmrCE23vjeN4WKfgWkc5DoqyMVdqWnWFpPAjvFfmTIwERwZaMyqhCKgL44XEif

Duke School of Medicine Technology Request Form

Please complete the form below. A group consisting of multiple departments within the School of Medicine (Information Security, Office of Research Contracts, Privacy, IRB, Compliance) will meet to evaluate your request and provide guidance on the best path forward.

Thank you!

Request Date:

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M-D-Y

Name of requestor:

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Phone Number at which you can be reached:

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Enter the email at which you prefer to be contacted regarding this request:

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Which of the listed areas would this request fall into?

Clinical Research

Basic Science

Research Administration

Medical Education

Other

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Please describe your request, including the problem you are trying to solve:

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Please enter your department or Clinical Research Unit:

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Enter your CRU/Dept:

Please briefly describe the project you are starting/problem you are trying to solve:

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Please briefly describe what you need for your project/solution:

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Do you have an IRB Protocol (either draft or submitted):

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Yes

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Please enter the protocol number:

Please upload a copy of the protocol so we can review.

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Upload file

Enter ServiceNow Demand Number (if submitted):

Does or will this project involve vendors, subcontractors, or collaborators outside of Duke?

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Yes

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Please enter contact information for all non-Duke vendors/collaborators:

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Is this project currently funded?

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Yes

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What is the funding source?

Sponsor Name:

Please detail the funding source:

Grant Number:

Does this project involve transmission or storage of PHI?

Click here for list of HIPAA Identifiers

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Yes

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Does this project involve a device, mobile or otherwise?

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Yes

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Does the device need to connect to the Duke network (wired or wireless) or a Duke computer?

Yes

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Is there a contract or statement of work for this project?

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Yes

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Which group are you currently collaborating with?

Please upload the agreement and any other related documents.

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Do you have a budget plan for this project?

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Yes

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Please upload your budget documentation.

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Please enter the name of the group you are collaborating with:

When do you intend to begin study activities?

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If study activities can begin prior to the solution being in place, when do you need the proposed solution in place?

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Upload file

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