Rx-SafeNet Request To Collaborate Form

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Please review Collaborating Investigator Information located at: https://www.pharmacy.purdue.edu/rx-safenet/resources/Info_for_Collaborating_Investigators.pdf prior to submitting the Request to Collaborate Form. If you have any questions, please email rx-safenet@purdue.edu in addition to submitting this form.

Thank you!

First Name:

Last Name:

First Name:

Last Name:

Title:

Primary Institution Affiliation:

Primary IRB:

Phone number:

Fax:

Email:

If you have an existing grant proposal or IRB protocol that you are willing to share, please upload it here:

Grant proposal:

Upload file

IRB protocol:

Upload file

1. Provide your short project title (1-5 words) for communication purposes within Rx-SafeNet.

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2. What is the focus of the project you are interested in completing? (e.g., MTM, medication safety, etc.)

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3. What is the specific question you want to answer as part of the project?

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4. Have you had an opportunity to review relevant scientific literature? If so, please summarize briefly (include references; may use background section from existing grant proposal if applicable).

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5. Please provide a detailed description of your participant eligibility criteria (e.g. Community pharmacists that provide MTM services, patients aged 65 and older, patients with diabetes, etc.)

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6. What will participants do as part of the project? Please provide a brief overview of study design and procedures (include duration of project activities and/or anticipated timeline).

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7. Please indicate resources needed from Rx-SafeNet below.

Recruitment of pharmacies/pharmacists and/or data collection assistance

Study design review

Identification of a collaborator(s)

Use of equipment/resources (iPads, Qualtrics, RedCap)

Help with identification of funding sources

Other

If other please specify:

8. Do you have funding for your project?

Yes

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What are your plans for submitting a grant and/or obtaining funding?

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What is the name of the grant/funding source?

Do you have IRB approval yet?

Yes

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Do you need a letter of support from Rx-SafeNet for a grant and/or IRB?

Yes

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Is there a specific date you need your letter of support by?

Yes

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What date do you need the LOS completed by?

M-D-Y

Please complete the funding query form for your project in addition to this form

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