Recruitment Request - DFMCH Research Services Hub

This form is used to facilitate the review and approval process by clinic leadership for investigators interested in recruiting from clinics affiliated with the Department of Family Medicine and Community Health. If you are also interested in recruiting patients from MHealth Fairview using MyChart or USPS letters, please review the Fairview Research Recruitment Services website below and complete the Fairview Research intake form.

Fairview Research Services

If you have any questions, please contact us at pcrln@umn.edu.

Name*

Email*

Phone Number*

Project Title*

Organization*

Project PI*

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

What Clinic(s) you would like help from?

Please explain*

How many patients do you hope to recruit from these clinics?

Inclusion/Exclusion criteria

What will patients be asked to do?

Other Description

Will participants be asked to attend in-person visits

Please specify

What are you asking the clinic physicians/staff to do?

Please describe what you are asking the clinic physicians/staff to do.

Please describe how the staff will help implement the study plan

How will this project benefit our patients or clinic?

Anticipated Start Date

Anticipated End Date

What stage is your project's IRB protocol?*

Please explain*

Is there financial support?

Would you like to meet with the clinic research committee?

Would you be interested in future collaborations with Family Medicine?

Is there opportunity for faculty and/or residents to be involved in scholarship resulting from this project/study?

Will transportation costs be covered or arranged for participants?

Will there be incentives for participants?

Please describe

Are non-English speakers eligible to participate?

Languages

Please specify

Will interpreters be available?

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.

Uploaded Supporting Documents

Contact Information

Recruitment Information

Recruitment Details

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