Table 4 Registry Data Request Form

Name of PI

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PI Role/ Title

PI Department

PI Email

Are you the PI?

Y/N

Are you (or the PI) already named as a Co-Investigator in either the Medical Student Registry or the Resident Registry IRB?

□ Co-Investigator in the MEDICAL STUDENT Registry

□ Co-Investigator in the RESIDENT Registry

□ None of the above

□ Not sure

Please list all relevant collaborators:

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Please describe your proposed study’s RESEARCH QUESTION.

Please indicate which of the following groups are included in your proposed study’s SAMPLE:

□ Medical Students

□ Residents

□ Fellows

□ Other

Please describe your SAMPLE in greater detail (e.g., Class year or cohort, etc.).

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Please indicate which of the following routinely collected educational data you would like to include in your proposed study:

□ Knowledge exams

□ Peer assessments

□ OSCE performance

□ Assessments of clinical performance

□ Shelf Exams

□ Step Exams

□ Board and/or In-Service Exams

□ 360 Assessments

□ EHR/EMR (including chart reviews)

□ Panel performance data

□ Pre- and post-curriculum questionnaire data

□ Program evaluation/QI data

□ Needs assessment surveys/questionnaires

□ Admissions/entrance data

□ OTHER

Please describe the data sets in greater detail and/or specify which OTHER data you are interested in.

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When do you plan on using this data for your study?

Please describe the general research design you are using in this proposed study.

Does this study involve ONLY routinely collected educational data?

Y/N

Does this study involve ONLY routinely collected educational data?

Does this study introduce any new curricular activities or interventions that are being conducted SOLELY for the purpose of research?

Does this study involve collecting new or additional data from learners SOLELY for the purpose of research?

Is the delivery or the content of educational materials and/or experiences being affected by the proposed research study?

Are you able to obtain the routinely collected educational data for your study?

Do the routinely collected educational data elements include the learners’ names or other identifier (e.g. Kerberos ID)?

How does the proposed study seek to contribute to improvements in medical education?

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Any additional questions or concerns you would like to share?

Please attach a copy of your current CV/Resume.

File upload

Please attach a copy of your current CITI Training Completion Report.