PLEASE READ: HERE DO NOT
Add your signature confirming that you have read and agree to the ICTR requirements/restrictions to receive ICTR resources.
* must provide value
Please indicate that you have read and agree to the attached ICTR requirements for receiving ICTR resources
* must provide value
Yes No
Yes No
IS THIS REQUEST TO SUPPORT COVID-19 research?
* must provide value
Yes No
1. Date of Request:
* must provide value
Today M-D-Y
2. Last Name:
* must provide value
3. First Name:
* must provide value
4. Terminal Degree:
* must provide value
DDS DMD DMsc DNP DO DrPH DS EdD JD MBBS MD PharmD PhD ScD Other
5. Academic Rank:
* must provide value
Assistant Professor Associate Professor Professor Other
5.a.
Unfortunately, you are not eligible for ICTR resources. At this time, ICTR resources and funding are available only to Assistant Professor, Associate Professor, and Professor Faculty.
6. School Affiliation (primary):
* must provide value
UMB School of Dentistry UMB School of Social Work UMB School of Pharmacy UMB School of Nursing UMB School of Medicine UMB Francis King Carey School of Law UMB Graduate School UMB Campus UMBC UMCP JHU
Please note that JHU Faculty are eligible for the UMB ICTR Drug Discovery Development (DDD) Core services only.
6.a.
7. Department/Division (primary)
* must provide value
Or, entity if request is from UMB Campus level
8. Are you a University of Maryland Greenebaum Comprehensive Cancer Center (UMGCCC) member?
* must provide value
Yes No
9. Have you been awarded an ICTR Pilot Grant (e.g., ATIP, CEnR, NSRP, etc.)?
* must provide value
Yes No
9.a. Is this resource request to support that ICTR Pilot Grant project?
* must provide value
Yes No
If Yes, please enter the same project title in the Project Title field below.
9.b. Are you the Lead PI of the ICTR Pilot Grant project?
Yes No
9.c. Please enter the ICTR Pilot Grant ID# (noted on your award letter):
* must provide value
Email ICTR-Navigator@umaryland.edu if not sure what your ATIP Project ID is.
The Lead PI of the funded pilot grant must be the person requesting the ICTR resources to support the ICTR pilot grant. This is to avoid duplicate reporting of publications, extramural funding, and/or IP from this request and the funded ICTR pilot grant project. Please contact the Lead PI to submit an ICTR Resource Request. Thank you, ICTR Leadership
10. Are you a UMB ICTR/CTSA KL2 Scholar?
* must provide value
Yes No
10.a. Is this request for ICTR services to help support your KL2 project?
* must provide value
Yes No
11. Are you a UMB ICTR/CTSA TL1 scholar mentor?
* must provide value
Yes No
11.a. Is this request for ICTR services to help support the TL1 scholar's project?
* must provide value
Yes No
11.b. TL1 scholar's last name:
* must provide value
11.c. TL1 scholar's first name
* must provide value
12. Your Campus Email Address:
* must provide value
Please, Do Not Use Personal Email Address.
Archived Email Address
Instructions: Please copy applicants contact email address here and delete from above for those projects that are
closed related to ATIPs and Scholars projects that requested but did not receive ICTR resources draft applications that were never submitted Purpose: by default, the survey distribution sends the semi-annual report on Grants, Publications, Inventions to the contact email. The only way to stop them from receiving the report request is to delete their contact email. However, because the email contact may be needed in the future, it is helpful to archive it.
13. Best Contact #:
* must provide value
Best contact number to reach you for questions or clarifications.
14. 16-digit Open Research and Contributor ID (ORCiD)*
* must provide value
16 digits PLUS the dashes (e.g. 1111-2222-3333-4444)
1. Project Title:
* must provide value
2. Brief Project Description and Statement on Why ICTR Resources are Needed:
* must provide value
3. Yes No
4. Is this Project Currently Funded?
* must provide value
Yes No
4.a. Funding Source:
* must provide value
Federal State Foundation Other
4.b.
4.b.
5. Extramural Grant Applications Planned for the Future:Describe your plans for extramural grant/funding application(s) using the data arising from this project. Please note specific funding mechanisms, RFAs, FOAs, and time frame for submission.
* must provide value
6. Peer-Reviewed Publication Plans for the Future:Describe your plans for peer-reviewed publication submissions using data from this project. Please name the targeted journals.
* must provide value
1. Human Subjects Research?
* must provide value
Yes No
2. IRB Reviewed and Approved?
* must provide value
Yes No
Please Note: Do Not Reference an IRB Protocol That You Are Not The PI of. Only the PI of the IRB Protocol Can Request ICTR Resources Related to That Protocol
2.a. IRB Approval/Decision Pending?
* must provide value
Yes No
3. Your IRB Protocol #:
* must provide value
4. Please Upload PDF of CICERO Protocol here
* must provide value
5. Please Upload IRB letter here
* must provide value
1. Research Involving Use of Animals?
* must provide value
Yes No
2. IACUC Reviewed and Approved?
* must provide value
Yes No
2.a. IACUC Approval/Decision Pending?
* must provide value
Yes No
3. IACUC Protocol#:
* must provide value
4. Please Upload IACUC Approval Letter Here
* must provide value
1. Do you need biostatistical services?
* must provide value
Yes No
If 'Yes', please select from branching menu.
2. Biostatistical Services:
* must provide value
Check all that apply.
You requested access to outside data sources, such as CMS and IQVIA data in the PHSR Community Database, DHMH, UMBC, etc). These services require a Voucher application. Please see Voucher Application request section at the end.
2.a. Please provide brief description of biostatistical need(s)':
* must provide value
2.a.
1. Do you need Community and Collaboration Core services?
* must provide value
Yes No
If 'Yes', please select from branching menu.
2. Community and Collaboration Services:
* must provide value
Due to the time-intensity of each of the above, please consider selecting only 1 option.
2.a.
2.a. Please provide brief description of Community and Collaboration Core need(s)':
* must provide value
1. Do you need Dissemination & Implementation services?
* must provide value
Yes No
If 'Yes', please select from branching menu.
2. Dissemination & Implementation Services:
* must provide value
Due to the time-intensity of each of the above, please consider selecting only 1 option.
2.a.
2.a. Please provide brief description of Dissemination & Implementation Core need(s)':
* must provide value
1. Do you need Drug Discovery and Development services?
* must provide value
Yes No
If 'Yes', please select from branching menu.
2. Drug Discovery and Development Services:
* must provide value
Check all that apply.
2.a. Please provide brief description of drug discovery and development need(s)':
* must provide value
E. ICTR INFORMATICS CORE SERVICES Examples of Informatics Core Services: Access to Clinical Data, REDCap, Dissemination & Implementation Consultation, UMBC Cybersecurity & AI Services, Digital Health Technology (such as Mobile Apps) Visit ICTR Website for Overview
1. Do you need Informatics services?
* must provide value
Yes No
If 'Yes', please select from branching menu.
2. Informatics Services:
* must provide value
Check all that apply.
2.a.
You have requested an EPIC data pull. Please upload the completed EPIC Data Request_Additional Elements form using the option on the right.
The template can be found HERE in the drop down under ICTR Informatics Core Services section.
* must provide value
2.a. Please provide brief description of Informatics need(s)':
* must provide value
2.a. Please provide brief description of 'UMBC Cybersecurity & AI Service need(s)':
* must provide value
You indicated above that you would like assistance Developing a REDCap Database and Survey/Data Entry Instruments, Qualtrics Survey Instrument, or TeleForm Data Collection Instruments. Please note, you will need to provide the Informatics team with a detailed list of the data elements you plan to collect and your data collection plan/schedule. Please upload below. If you have not yet decided on these elements, please unselect and consider a consult with the Biostatistics team (see above) or a Studio session (see below). We can update your application for these Informatics resources when you are ready. For more information about REDCap, Qualtrics, and TeleForms as well as examples of typical research data elements and a data collection schedule, please visit the
ICTR Data Management webpage Please upload your project's detailed list of data elements and data plan/collection schedule:
* must provide value
1. Do you need Studio services?
* must provide value
Yes No
If 'Yes', please select from branching menu.
2. Studios Consult Format Desired:
* must provide value
Check all that apply.
2.a.
3. Please upload a draft of your research proposal and a numbered list of the specific questions/concerns you would like guidance on. This will assist with assembling the appropriate team of experts for the Studio session.
* must provide value
1. Are You Requesting a Voucher Application? PLEASE NOTE! Human Subjects Research must have IRB approval prior to submitting a Voucher application. Live Vertebrae Animal research must have IACUC approval covering the experiments planned in the proposed research prior to submitting a Voucher application. Exceptions cannot be made.
* must provide value
Yes No
2. Please list NON-ICTR Core services needing Voucher support for this project:
* must provide value
Your request for a Voucher application will be reviewed. If your request for an application is approved, you will receive a link to your application where you can upload the supporting documents.
Ok to send Voucher Application Link?
Yes No
This Automatic Voucher Survey Application Form Button Was Added July 2018 to Minimize Admin Burden of Manually Emailing Voucher Application Links.
1. Help the ICTR improve its outreach. Tell us how you learned about the ICTR resources?
* must provide value
Colleague Department/Division Leader Faculty Member NIH Website JHU Website Howard Website Posters/Flyers Attended Information Session in person Attended Information Session online Elm ICTR Newsletter ICTR Website Twitter Other
YOU HAVE NOT SELECTED ANY SERVICES OR A VOUCHER APPLICATION. PLEASE REVIEW BEFORE SUBMITTING.
Submit
Save & Return Later
