Due Date quote is needed by
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Today M-D-Y
If external funding, due date for submission to the sponsor
Today M-D-Y
Project Title
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Principal Investigator Name (First and Last)
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Principal Investigator E-mail address
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Principal Investigator phone number
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Principal Investigator Role
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Administrator Nurse Pharmacist PhD Researcher Physician Researcher Other
If other, please provide role.
Principal Investigator Institution
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Indiana University Purdue University University of Notre Dame Other
If other, please give the name of the prime institution.
Co-Principal Investigator(s) Name (First and Last)
Co-Principal Investigator(s) E-mail
Project Manager Name (First and Last)
Project Manager phone number
Business Manager/Pre-award Administrator Name (First and Last)
Business Manager/Pre-award Administrator E-mail
Business Manager/Pre-award Administrator phone number
Name of Person Submitting Quote Request (if other than PI)
Email of Person Submitting Quote Request (if other than PI)
Formal Quote (RI Letterhead & Signature)
Informal Quote (ballpark estimate of services)
Have you submitted a data request (https://www.regenstrief.org/data-request/ ) related to this quote request?A data request does not need to be submitted at the same time as your quote request unless you have funding and are ready for work on your project to begin.
It is recommended that you submit your data request as soon as you have both funding and IRB approval.
Yes
No
Date of the data request (the approximate date is acceptable if the exact date is not known)
Today M-D-Y
If known, ticket number for your data request
Is this a new proposal or continuation of an existing project?
New
Continuation
Funding granted or applied for?
Granted Applied For Pending Will Apply
Funding Source/Grant Name
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If industry-sponsored, will the funding be coming directly from the industry sponsor or will it be flowing through another entity?
Directly
Flow through
Is this part of a larger proposal being submitted by Regenstrief?
Yes
No
Is this a multi-year project?
Yes
No
Today M-D-Y
Today M-D-Y
Is the time frame during which RDS is needed different than the project period specified on the award/budget?
Yes
No
RDS Engagement Start Date
Today M-D-Y
Today M-D-Y
Proposed Project Start Date
Today M-D-Y
Proposed Project End Date
Today M-D-Y
Expected Regenstrief Data Services Start Date
This may differ from the project start date.
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Today M-D-Y
Expected Regenstrief Data Services End Date
This may differ from the project end date.
* must provide value
Today M-D-Y
Does your project require a dataset or other deliverable only, or does it also require consultation with an analyst/engineer?Consultation includes having an analyst/engineer available during regular meetings, the design phase, and/or any other commitments/communications outside of those needed to provide one or more project deliverables.
Deliverables only
Deliverables AND consultation
Unsure/Request to discuss
Do you anticipate having RDS staff attend regular team meetings through the duration of the project?
Yes
No
If so, what is the anticipated frequency and lengths of these meetings?
Does this study involve the use of AI or LLM?
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Yes
No
Will your project require the effort of Regenstrief chart reviewers?
Yes
No
If your project will include chart reviews conducted by your team or another entity outside RDS, please select 'No'
Will you be using REDCap to store any of the data received from RDS?
Yes
No
Unsure
Who will build your REDCap project? Please note that if you request that RDS builds your REDCap project, we will include this cost in your estimate. If you are unsure at this time, you can opt to request that RDS build your REDCap at a later time, and we will provide a revised estimate and instructions then.
Regenstrief Data Services (please include this cost in the requested estimate)
Study team, investigator, or other service provided by investigator's institution
Other
Unsure at this time
Please briefly describe who will build your REDCap project.
Will the project include a 3rd party institution/vendor?
Yes
No
Not Sure
Project Description:If specific software will be required, please include this information here.
* must provide value
Data elements needed:Either data elements (e.g. Medications, Encounters, Diagnoses, procedures, demographics, Labs, Orders, SDOH, Location-based data, Indices (such as Charlson, Elixhauser, Social Vulnerability, etc.) or specific variables (e.g., age, race, diagnosis, service area, PCP, etc.) may be listed. each PHI variable must be listed in your IRB protocol submission .
* must provide value
Does your project require either free text notes or the extraction of data from free-text notes?
Free text notes
Extraction of data from free-text notes (by RDS)
Both
Neither
Cohort Inclusion Criteria:
Example: all female patients with a visit with an ICD-9 code of 780.3x and/or 345.x whose age is greater than 50 and less than or less than or equal to 75.
Please avoid using "< " or ">" symbols in this text box, as it causes errors in our ticketing system and can delay our response.
Cohort Exclusion Criteria:
Please avoid using "< " or ">" symbols in this text box, as it causes errors in our ticketing system and can delay our response.
Data capture date range (MM/DD/YYYY to MM/DD/YYYY):
Does the project require:
a single deliverable (such as a one-time data pull or recruitment list, with or without refreshes), OR multiple deliverables over time
Single deliverable, one-time data pull
Single deliverable with refreshes (see below)
Multiple deliverables over time
Other
Please describe the type(s) of deliverable(s) your project requires and their frequency
Does your project require a one-time recruitment or chart review list ONLY?
NOTE : A recruitment or chart review list may ONLY contain the variables MRN, DOB, race, and gender.
* must provide value
Yes
No
Unsure
Does the data need to be refreshed?
Yes No
If yes, what will be the frequency of the refreshes?
Monthly Quarterly Every 6 months Annually Other
If Other, please specify frequency:
Data Sources:
* must provide value
INPC data includes over 100 separate healthcare entities statewide, including IUH and Eskenazi. The Eskenazi EDW and IUH EDW each include data only from their respective institutions, and include a greater variety and depth of clinical data than INPC. For more information on data sources available through RDS, see https://www.regenstrief.org/rds/data/
If Other, please list data sources:
Upon completion of the project; what is your expectation for product delivery: (Check all that apply.)
If other, please tell us what you envision.
Will your project require any of the following: use of cloud services (AWS, Azure, GCP), FISMA compliance, or similar?
* must provide value
Yes
No
Will the data provided by RDS be shared with any entities external to IU or Regenstrief?
* must provide value
Yes
No
Do you have any documents you would like to attach to explain your request in more detail? (Examples: Specific aims, variable lists, etc.)
Yes No
Please attachment your document here
Please attachment your document here
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