Request Date* must provide value
Today M-D-Y
Timestamp you can calculate with
Today M-D-Y
Year
Fiscal Year
RequestID
Your Name * must provide value
Your Email * must provide value
What is the best way to reach you? Phone
E-mail
What is your Phone Number?* must provide value
Your Role* must provide value
Principal Investigator Research Nurse Research Associate Financial Contact Sub Investigator Coordinator Regulatory Specialist Other
What is your role?* must provide value
Institution* must provide value
UMass Chan - Worcester/UMassMemorial
UMass Amherst
UMass Boston
UMass Dartmouth
UMass Lowell
UMass Chan - Baystate Health Care
UMass Chan - Lahey
Other
Institution (other)* must provide value
Department* must provide value
Anesthesiology & Perioperative Medicine (W8229009NN) Biochemistry & Molecular Pharmacology Cancer Center (W4025009NN) Dermatology (W8230009NN) Emergency Medicine (W8230009NN) Family Medicine & Community Health Gene Therapy Center (W4052009NN) Medicine (W7100009NN) Medicine - Behavior & Preventive Medicine (W71007006NN) Medicine - Cardiovascular Medicine (W7100109NN) Diabetes Center of Excellence (W7100259NN) Medicine - Endocrinology (W7100359NN) Medicine - Gastroenterology (W7100409NN) Medicine - Rheumatology (W7100859NN) Meyers Primary Care (W8020200000) Microbiology & Physiological Systems Molecular, Cell & Cancer Biology Molecular Medicine (W4009009NN) Neurobiology Neurology (W8325009NN) Neurosurgery Obstetrics & Gynecology (W8255009NN) Ophthalmology & Visual Sciences (W822000000) Orthopedics & Physical Rehabilitation (W8250009NN) Otolaryngology Pathology Pediatrics (W8335009NN) Pediatrics - Hematology/Oncology (W8335159NN) Population & Quantitative Health Sciences Psychiatry (W8330009NN) Radiology / Nuclear Medicine (WW822500000) Radiation Oncology (WW82750000) RNA Therapeutics Institute Shriver Center (W408200ALL) Surgery (W8240009NN) Urology (W8370009NN) Graduate School of Nursing Other Organization Clinical Research Center CCTS / OCR / Core Services Staff OSP/Bridge Central Office
Department (other)
As a CCTS, OCR, or Core Services Staff member, do you want to:
1) enter a full request (requires uploading required documents)
or
2) back enter a request for tracking purposes (no document uploads)* must provide value
Enter a complete request (required documents)
Back enter a request (no required documents)
Please provide a brief summary of your consult request* must provide value
Please upload any relevant document needed for the consult
Please use this to upload a 2nd file (if needed)
If applicable, what is the deadline for this request?
Today M-D-Y
Please indicate if this request is related to a COVID-19 study so we can prioritize the request, as appropriate. This is a COVID-19 study request
Biorepository - COVID-19 samples request for samples in Biorepository
Contract related question
Ongoing studies question
IRB related question
Guidance clarification
Other
Is this request associated with the Rapid Acceleration of Diagnostics (RADx) NIH initiative?
Yes
No
Please describe your COVID-19 question.
Protocol service requested Multiple choices allowed. Choose OCR : Contracts & Budgeting for: DUA/CDA/NDA/CTA, New Grant, or Study Account closure Study amendments (protocol/contract/budget)
Revise OnCore Information COC or IPA Update/revise Conquering Diseases
Choose IRB Consult for:
Extramural Institutional Certification
EPIC - new user account for Clinical Trial Management
DocuSign 21 CFR Part 11 Compliant Account (incurs charges to use)
Are you working with a PI affiliated with UMass Medical School?* must provide value
Yes
No
Who is the UMass PI?* must provide value
What is the PI's Department?* must provide value
Anesthesiology & Perioperative Medicine (W8229009NN) Biochemistry & Molecular Pharmacology Cancer Center (W4025009NN) Dermatology (W8230009NN) Emergency Medicine (W8230009NN) Family Medicine & Community Health Gene Therapy Center (W4052009NN) Medicine (W7100009NN) Medicine - Behavior & Preventive Medicine (W71007006NN) Medicine - Cardiovascular Medicine (W7100109NN) Diabetes Center of Excellence (W7100259NN) Medicine - Endocrinology (W7100359NN) Medicine - Gastroenterology (W7100409NN) Medicine - Rheumatology (W7100859NN) Meyers Primary Care (W8020200000) Microbiology & Physiological Systems Molecular, Cell & Cancer Biology Molecular Medicine (W4009009NN) Neurobiology Neurology (W8325009NN) Neurosurgery Obstetrics & Gynecology (W8255009NN) Ophthalmology & Visual Sciences (W822000000) Orthopedics & Physical Rehabilitation (W8250009NN) Otolaryngology Pathology Pediatrics (W8335009NN) Pediatrics - Hematology/Oncology (W8335159NN) Population & Quantitative Health Sciences Psychiatry (W8330009NN) Radiology / Nuclear Medicine (WW822500000) Radiation Oncology (WW82750000) RNA Therapeutics Institute Shriver Center (W408200ALL) Surgery (W8240009NN) Urology (W8370009NN) Graduate School of Nursing Other Organization
Department (other)
Based on responses - determine whether the requester can order services from the CRC, OCR, IDS, or PRC. View equation
Use of protocol services such as the Clinical Research Center, Investigational Drug Services, and Contracts & Budgeting services require a UMass-affiliated PI. If you need assistance identifying a collaborator, please request a research navigator service consultation. Number of protocol requests View equation
Number of COVID-19 requests View equation
Recruitment service requested
Multiple choices allowed.
Recruitment Core:
Recruitment alerts, registries, cohort identification,
request volunteer info from Conquering Disease or ResearchMatch, data sets from Data Lake for recruitment, Recruitment Core consultation
Data Science Core:
Data sets from Data Lake for retrospective studies, Data Science Core consultation
Question about Conquering Diseases website
Informatics: Recruitment Core, Research Informatics, TriNetx
Research Navigator Service (consult)
Number of recruitment requests View equation
Other type of service requested
Multiple choices allowed.
Choose Miscellaneous Study Conduct for:
* Copy of Lab Certifications
* Information about MCSR (Massachusetts Controlled Substances Registration)
* Adding a sponsor to eIRB
* Adding a "New Drug" to eIRB
Miscellaneous Study Conduct (e.g. lab certs, MCSR, add sponsor or "New Drug" to eIRB, etc)
I can't find what I need
Number of other requests View equation
Total number of services View equation
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