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Table 4 Registry Data Request Form

From: Development and maintenance of a medical education research registry

QuestionsResponse Options
Demographics
Name of PIText box
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
Research Study Details
Please list all relevant collaborators:Text box
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.).Text box
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.Text box
When do you plan on using this data for your study?
Please describe the general research design you are using in this proposed study.
Confirmation of Eligibility for Registry
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?Text box
Any additional questions or concerns you would like to share?
Mandatory Documents
Please attach a copy of your current CV/Resume.File upload
Please attach a copy of your current CITI Training Completion Report.