Recruitment Request - DFMCH Research Services Hub

Project Principal Investigator/Project Lead name*

Organization e.g., College, Department, Center*

Email address*

Are you a Department of Family Medicine and Community Health (DFMCH) faculty member?*

Are you adjunct or affiliate faculty?*

Have you discussed your project with anyone at the DFMCH?*

Please specify

Preferred contact method (check all that apply)*

If the submitter is not the Principal Investigator/Project Lead, please include the submitter's contact information

Submitter Name (if different than PI)*

Submitter Email Address (if different than PI)*

Submitter Phone Number*

Phone number*

What is this request for? (Check all that apply)*

The Collaboration Request form helps facilitate the review and approval process by clinic leadership for investigators wanting to collaborate with clinics affiliated with the University of Minnesota Department of Family Medicine and Community Health's (DFMCH) Primary Care Research Learning Network (PCRLN).

Note: All projects must receive UMN IRB approval, including Fairview ancillary review as applicable in order to recruit from M Health Fairview clinics.

Below are steps outlining the review and approval process:

Submit a Collaboration Request Form: Investigators interested in collaborating with PCRLN clinics must submit a "Collaboration Request" form. Please ensure that all sections of the form are fully completed to help us assess your needs and current stage in the research process. Completing the request form will take about 10 minutes.
Communication Regarding the Request: Once submitted through the portal, your request will be routed to the PCRLN for review. A team member may contact you via email to request additional information about your collaboration request.
Clinic Review Process: After the request is reviewed, Research Facilitators at designated clinics will discuss the request with their clinic's research review committee and leadership teams to assess feasibility and interest. A team member may contact you with questions in response to your request during this process.
Clinic Decision: Decisions regarding the request will be communicated with you via email and/or Zoom meeting as they are made. Please note that each clinic has a unique review process and request review may take up to 4-6 weeks.

The Patient Recruitment form helps facilitate the review and approval process by clinic leadership for investigators wanting to recruit from clinics affiliated with the University of Minnesota Department of Family Medicine and Community Health's (DFMCH) Primary Care Research Learning Network (PCRLN).

Note: All projects must receive UMN IRB approval, including Fairview ancillary review as applicable, in order to recruit from M Health Fairview clinics.

Below are steps outlining the review and approval process:

Submit a Patient Recruitment form: Investigators interested in hanging flyers for recruiting participants from PCRLN clinics must submit a "Patient Recruitment" form. Please ensure that all sections of the form are fully completed to help us assess your needs and current stage in the research process. Completing the request form will take about 10 minutes.
Communication Regarding the Request: Once submitted through the portal, your request will be routed to the PCRLN for review. A team member may contact you via email to request additional information about your recruitment request.
Clinic Review Process: After the request is reviewed, Research Facilitators at designated clinics will discuss the request with their clinic's research review committee and leadership teams to assess feasibility and interest. A team member may contact you with questions in response to your request during this process.
Clinic Decision: Decisions regarding the recruitment request will be communicated with you via email and/or Zoom meeting as they are made. Please note that each clinic has a unique review process and request review may take up to 4-6 weeks.

If you are also interested in recruiting patients from M Health Fairview clinics, including Bethesda, Smiley's and Phalen Village, through phone calls, MyChart, and/or mailing letters via USPS, please review Fairview Research Recruitment Services website and complete their Fairview Research Intake Form. Please note there are fees for these services.

Project Title*

Description of Project
If this project is a clinical trial please provide the clinicaltrials.gov link below.

Study Type

Please specify.*

What stage is the project in?

Is the study considered human subjects research?

Anticipated Start Date

Anticipated End Date

Is this project receiving funding?

Who is the funder?

Please specify.

Please add the link to the funding mechanism

Will PCRLN clinics be compensated?

Please provide a brief description of the compensation plan for the clinic, clinicians and/or staff for their effort and time spent on this project.

How will this project benefit our clinics, clinicians, patients and/or community? (Check all that apply)

Please specify.

Have patients or community members been involved in the development of the project?

Please specify.

Which clinic(s) would you like help from? (Check all that apply) Research Learning Network

What role(s) can clinic employees (e.g., providers & staff) play within the PCRLN? (Check all that apply)

Who will be recruited?

Please specify.

Specify the number of patients needed from selected clinic(s).

What is the inclusion criteria?

What is the exclusion criteria?

What will patients be asked to do?

Please specify.

Will patients be asked to attend in-person visits?

Where will visits be conducted?

Will transportation costs be covered or arranged for participants? (transportation is often a barrier for patients)

If visits are to be completed in PCRLN clinic(s), please also select "Collaboration Request" under "What is this request for?" and complete the additional questions

Are patients compensated?

Compensation amount.

What languages are eligible for inclusion in your project?

Please specify.

Specify the number of providers needed from selected clinic(s).

What is the inclusion criteria?

What is the exclusion criteria?

What will providers be asked to do? (Check all that apply)

Please specify

Specify the number of clinic staff needed from selected clinic(s).

What is the inclusion criteria?

What is the exclusion criteria?

What will clinic staff be asked to do? (Check all that apply)

Please specify

Specify the number of residents needed from selected clinic(s).

What is the inclusion criteria?

What is the exclusion criteria?

What will residents be asked to do? (Check all that apply)

Please specify

Specify the number of faculty needed from selected clinic(s).

What is the inclusion criteria?

What is the exclusion criteria?

What will faculty be asked to do? (Check all that apply)

Please specify

Specify the number of [other] needed from selected clinic(s).

What is the inclusion criteria?

What is the exclusion criteria?

What will [other] be asked to do? (Check all that apply)

Please specify

Who would you like to help with the recruitment?

Please specify.

What are you asking research facilitators to do? (Check all that apply)

Please specify.

What are you asking clinic staff to do? (Check all that apply)

Please specify.

What are you asking clinic providers to do? (Check all that apply)

Please specify.

What are you asking residents to do? (Check all that apply)

Please specify.

What are you asking [other] to do? (Check all that apply)

Please specify.

What resources will the clinic(s) need to provide? (Check all that apply)

Please specify.

Please describe how information would be disseminated directly back to PCRLN membership, in addition to scholarly presentations and publications.

Upload Supporting Documents

Please upload any fliers or marketing materials for your project.
If this project involves informed consent, please upload the form participants will complete.

Would you like to be added to the PCRLN email list for additional practice-based research opportunities?

Where did you hear about the Primary Care Research Learning Network?

Principal Investigator/Project Lead Contact Information

If the submitter is not the Principal Investigator/Project Lead, please include the submitter's contact information

Request Type

Recruitment Information

If visits are to be completed in PCRLN clinic(s), please also select "Collaboration Request" under "What is this request for?" and complete the additional questions

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