Clinical Research Network Intake Form

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This form is required to facilitate review by BMC's Clinical Research Network Advisory Review Committee to determine the allocation of Clinical Research Network Resources. For an overview of the submission process, see Exhibit A

Clinical Research Network Aims: Provide study - specific staffing to rapidly activate and manage high priority, under-resourced trials. The Clinical Research Network can provide the following services:
  • Regulatory Management - IRB fillings and comprehensive regulatory management
  • Financial Management - budgeting, invoicing, and expense tracking/allocation
  • Clinical Research Coordinator - recruitment, pre-screening, consenting, data management, source documentation
  • Diversity, Equity and Inclusion (DEI) recruitment planning - In partnership with BMC's community engagement & External Affair team and the CTSI Community Engagement Program, guide and deploy study-specific diversity, equity and inclusion recruitment strategies.





Funding Source:




What is the enrollment status of this study across all sites?




Types of Study:

Phase of Study (for clinical trials):
Phase of study (Device):




Study Team (PI/Co-Is)
Please list full name and email of PI, any Co-Is, and any potential COI/Financial Interest for any study staff if applicable:







Clinical Research Network, Community Health Center & Ancillary Services
Budgeting: Please be advised that Clinical Research Network services, working with BMC's Community Health Centers, and seeking support by BMC Ancillary Departments require project budgeting. The exact cost varies by request and is determined by the resource and service needs of your research project. The CRN can work with the PI/study team and sponsors to negotiate appropriate funding.

 






CRN Services Requested:
Clinical Research Network Services Requested

BMC Affiliated Community Health Centers of Interest:

Ancillary Department Services

Study recruitment
Describe the patient population

Full Study Screening (Inclusion and Exclusion) Criteria:
Will subjects be recruited from outside of BMC's patient population?:
Anticipated challenges to enrollment: (i.e. are inclusive or exclusive criteria reasonable to meet enrollment?):
Risk Assessment
Does the study present more than minimal risk to human subjects?

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