First Name
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Last Name
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Email
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Phone Number
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Anesthesiology Campus Oversight Organization Central Administration (E.G., IRB, SOM Finance, DOCR, OCRC, etc.) Clinical And Translational Sciences Institute (CTSI) DCI/Oncology Dermatology/Pathology Duke Clinical Research Institute (DCRI) Duke Early Phase Research Unit (DEPRU) Duke Global Health Institute Oversight Organization Duke Human Vaccine Institute (DHVI) Duke Office Of Clinical Research Oversight Organization Family Medicine And Community Health Head And Neck Surgery And Commication Science (HNSCS) Heart Center Medicine Neurology Neurosurgery OB/GYN Office Of Curriculum Oversight Organization Ophthalmology Orthopaedic Surgery Pediatrics Pharmacy Services Oversight Organization Population Health Sciences Psychiatry Radiology School Of Nursing Surgery Other
Specify Other
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Are you the PI?
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Yes No
First Name
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Last Name
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Email
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RPM First Name
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RPM Last Name
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RPM Email
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First Name
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Last Name
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Email
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You may download a Facilities and Resources here .
Do you have a written protocol for the study?
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Yes No
Please upload the protocol provided
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Protocol/Project title
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Protocol/Project short title
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Do you have a DUHS protocol number?
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Yes No
IRB number
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Primary Funding Source
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NIH/Federal (for DOD or other federal funding to apply) Industry sponsor Department Funds Foundation Other
Specify other funding source
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How soon do you need someone to start working on your project?
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M-D-Y
Number of Participants
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estimate
Participant Type
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Select all that apply
Pediatric age
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Select all that apply
Therapeutic Target Area
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Allergy/Immunology Anesthesiology Cardiology Clinical Pharmacology Dermatology Endocrinology Gastroenterology Gerontology/Aging Health Service Delivery Hematology Infectious Disease Medical Genetics Neuropharmacology (Including Neurology, Psychiatry, Behavioral Health, And Pain Control) Nutrition Obstetrics/Gynecology Oncology Ophthalmology Orthopedics Pulmonary Rheumatology Urology Other
Specify other therapeutic type
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Approximate Service Duration
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Duration
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Weeks Months Years
Study Phase
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I II III IV Other
Specify Other Phase
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Please check all the interventions that apply
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Select all that apply
Specify Device
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Specify Other Intervention
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Coordination Service Required
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Lab Services Required
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Has a lab manual been provided?
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Yes No
Please upload the lab manual provided
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Are your visits outpatient, confinement, or both?
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Outpatient
Confinement (overnight)
Both
What is the total number of outpatient visits?
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Will you need the outpatient visits to take place over the weekend?
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Yes No
How many confinement visits for the duration of the study?
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How many nights per confinement visit?
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Number of expected participants per confinement visit?
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Will you need the confinement to take place over the weekend?
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Yes No
What services do you need assistance with recruitment for?
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When are services needed?
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The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Special equipment required
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Specify other equipment
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The option " " can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?
Participants physical limitations
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Specify other limitations
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Does protocol require any ancillary services?
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Yes No
e.g. Imaging, MRI, Stress test, Cath Lab, PET, etc.
Do any of your study visits include administration of investigational product?
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Yes No
Which of the following types of investigational products will you need administered?
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Specify Other
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COVID-19 Study
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Yes No