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Research
Collaboration
Questionnaire
Examples This document contains examples ofquestionnaires that community health centersask research investigators/teams to completeif they are interested in conducting research ator with their health center. Related Directory Resource:
Reviewing &
Considering Research Requests fromAcademics
Collaborating Agency :
Contact Person :
Phone # : E-Mail :
Project Title :
Type of Study :
Needs Assessment
Analysis of existing data
Data collection
Intervention
Brief description of project goals, objectives and activities :
Funding Source :
Total Funding Amount :
Funding Amount requested :
Funding Period :
Letter of Intent Deadline :
Proposal Deadline :
Does the researcher have previous experience with Community-Based Participatory
Research? ___Yes ___No (If Yes, please describe the experience.)
Name of the last community-based partner :
Contact person and information :
How does this project fit into the goals of AHS?
1. Increase the knowledge of API communities’ health issues ___Yes ___No
2. Research that is beneficial to the API population in the short and long run? ___Yes
___No (Please explain)
3. Does it build either AHS or community capacity? ___Yes ___No (Please explain)
List any past collaboration with AHS, including key AHS staff involved :
Collaborating AHS program/department for this project :
Amount/type of in-kind contribution sought from AHS :
AHS Staff and Role :
- Is an AHS staff either a PI or a co-PI? ___Yes ___No (If not, please explain.)
- What are the duties/ responsibilities expected from AHS?
- What kind of data or information is needed from AHS, if any?
ASIAN HEALTH SERVICES
RESEARCH COLLABORATION QUESTIONNAIRE
Building Primary Care Research Infrastructure At Your Community Health Center 2012
Collaborating with External Researchers Worksheet
BASIC RESEARCH REQUEST
- What is the name and contact information of the Principal Investigator(s) for this research?
- Is this research currently funded? If yes, please state the funding source.
- Is there any funding support for collaborators? If yes, please describe here.
- What are the research aims?
- What is the target population of interest?
- What is the expected research time frame? a. Start date: _________________________________ b. End date: _________________________________
- What is the Institutional Review Board (IRB) status for this research? (please check below) □ Developing IRB application □ Under review ____________________ □ Approved: _______________________
7a. What IRB(s) are currently reviewing this research?
- Is the researcher willing to submit an IRB at your CHC? (if applicable)
□ Yes Æ Who will serve as the investigator at your CHC for the IRB?_________________ □ No
Harvard Catalyst - Community Health Innovation and Research Program (CHIRP)
Building Primary Care Research Infrastructure At Your Community Health Center 2012
- Please describe the specific expectations for your CHC’s involvement in this research? (e.g. historic data, access to patients, recruitment, etc)
- What is the dissemination plan for this research?
Yes No Comments Will your CHC administration be able to see the data prior to publication? Will a provider at your CHC be included as an author on any publications? If so whom? Will a provider at your CHC have an opportunity to provide feedback on manuscripts prior to publication? Is there any entity other than the research team whose authorization is needed prior to dissemination?
CHC INTERNAL ASSESSMENT
Individual collaborator questions and implications
- How will I be involved in this research? (please check below) □ Co-Investigator □ Collaborator □ Other? ______________
- Does this research address an important problem relevant to my research interests?
- Will I have access to the data after this research is complete?
Institutional questions and implications
- Does this research address an important problem relevant to my CHC?
Harvard Catalyst - Community Health Innovation and Research Program (CHIRP)
Building Primary Care Research Infrastructure At Your Community Health Center 2012
Signature of CHC Medical Director(s)
Name_____________________________ Signature_____________________________
Signature of External Principal Investigator
Name_____________________________ Signature___________________________
Notes:
Harvard Catalyst - Community Health Innovation and Research Program (CHIRP)
