Today M-D-Y
Project Description/Notes:
• For research projects: include a short study description. • For TLI administration or CTSI internal core requests: use this space to provide any notes or instructions needed for Informatics to process your request.
Requester name
* must provide value
Enter your title and full name (e.g., Dr. Jane Smith).
Requester Email
* must provide value
Please provide Lundquist email. If you don't have one, please provide your institution or DHS email, please do not use your personal email
Is this request for TLI administration or internal core operation?(If Yes, No service fee or voucher is required. The survey will end and Your request will be processed automatically by CTSI Informatics.)
Yes No
Is this a research project?(*DHS clinical QI projects should not use REDCap to avoid potential conflicts with county regulations)
Yes No
IRB
*Is the project IRB approved? IRB Status IRB Number **Have you select CTSI and REDCap in your IRB Application? IRB approve date IRB expiration date
"Your project cannot be processed until IRB approval or exemption is obtained. Please complete your IRB review and return to submit this request later.
** CTSI and REDCap must be selected in your IRB application. This ensures that CTSI can access your project information in the IRB system to process your REDCap request.
Is the project IRB approved?
* must provide value
Yes No
IRB status
* must provide value
Approved Exempt In process N/A Not Approved
Have you select use CTSI and REDCap in your IRB application?
* must provide value
Yes No
click on "i" for more information; CTSI can not access IRB info if CTSI is not selected
IRB approve date
* must provide value
Today M-D-Y
IRB expiration date
* must provide value
Today M-D-Y
Upload IRB approved letter
Purpose of this project:
* must provide value
Research Clinical Care QI Operations Other (Please specify)
View equation View equation 2024 2025 2026 2027 2028 2029 2030
Yes No
Intention of publication?
Yes No
Yes No
Planned number of subjects?
Planned # of visits per patient
Duration of Project (Yrs)
Are you going to collect High Risk data (such as PHI):
Yes No
PI (Title+Full Name) PI Email Is PI/coPI TLI investigator If No, Other: Dept: Requester Role in Project:
If lots of non-Lundquist users need to be added to the project, please download the userimportTemplate.csv file. fill in users in the file and upload below.
How many sites? Planned # of subjects? Collect PHI? Duration of Project(Yrs) Intention of Publication? Industry Initiated?
If more than 1 site, please list other sites:
Estimate # of REDCap users: 1. List each user's Full Name and Institutional Email Address (Lundquist email preferred).Security note: Do not use personal email addresses. 2. Indicate which user(s) will have permission to design or modify the database . 3. Login credentials will be sent directly to each user by email. 4. The PI / Requester is responsible for: Assign special user rights beyond default roles. Set expiration dates for temporary users or employees who leave.
xAre you going to create project based on an existing XML file?
Yes No
UserimportTemplate file upload
Estimate # of REDCap users
REDcap users - Who need to and can access this REDCap project?
List each user's Full Name and Institutional Email (Lundquist preferred). Personal emails are not allowed.
Indicate which users can design or modify the database .
Login credentials will be emailed directly to each user.
The PI/Requester must manage user rights and set expiration dates for temporary users or users who leave.
User will receive login information by email. PI/Requester will be responsible for Defining special user rights other than the default rights and assign expiration date for the temporary or terminated employees.
If other, Please indicate
Do you have funding support including Dept. support to pay REDCap cost?
* must provide value
Yes No
Approved Applied/Pending Plan to Apply NA
Cost Charge Account (e.g. 10 digit project account#)
* must provide value
For Lundquist/Harbor UCLA, Please enter your 10 digit project account
Is PI/co-PI a Lundquist investigator?
* must provide value
Yes No
Are you HUMC/DHS employee/faculty?
Yes No
If you are Fellow, Resident or Junior investigator, please enter your mentor's name:
last, first
Is your mentor a current Lundquist investigator?
Yes No
What's your role in the project?
PI Name
* must provide value
Last, First
PI Email
* must provide value
Please enter your Lundquist email address if you have one
hidden survey
REDCap Budget Worksheet (click to view):
1. Base Hosting Fee
Category
Lundquist
Non-Lundquist
Applies To
Base Hosting Fee
$150/yr × # of years
$300/yr × # of years
All projects
2. Project Service Fee
(Hourly rate: $75/hr for Lundquist, $150/hr for Non-Lundquist)
a) Form Design
Project Size
Estimated Hours
Price Range (Lundquist)
Price Range (Non-Lundquist)
Typical Scope
Extra Small
< 8 hrs
$300 - $600
$600 - $1,200
Minor edits, small survey, quick project changes, < 5 users, < 50 records
Small
9-24 hrs
$600 - $1,800
$1,200 - $3,600
Simple new project, 1-3 forms/pages, basic logic, < 10 users, < 250 records
Medium
25-48 hrs
$1,800 - $3,600
$3,600 - $7,200
Full study setup with 4-8 forms/pages or longitudinal design or custom reports, < 20 users, < 500 records
Large
49-96 hrs
$3,600 - $7,200
$7,200 - $14,400
Full study setup with 9-12 forms/pages, longitudinal design or custom reports, < 30 users, < 1000 records
Extra Large
>96 hrs
>$7,200
>$14,400
Complex longitudinal study, multiple arms, advanced calculations, or external module integration
b) Service hours can also be purchased for:
Consultation/Training External Module Data import/export Any other REDCap task that requires intervention by CTSI staff Do you have funding support including Dept. support to pay REDCap cost? Funding status: Funding agency/source: Cost Charge Account (e.g. 10 digit project charge account#)
* If you don't have project charge account#, please specify how are you going to pay the invoice
Do you want to request a waiver of the REDCap base fee?(Qualification: IRB-approved, trainee/junior-led, unfunded, self-service REDCap.)
Yes No
If yes, Self-eligibility form need to be filled below
Is the project led by a fellow, trainee, or junior investigator?
* must provide value
Yes No
If you are Fellow, Resident or Junior investigator, please enter your mentor's name: Your mentor/supervisor's email: Is your mentor a current Lundquist investigator?
Do you have other funding support for this project?
* must provide value
Yes No
Do you need services beyond basic access and support?(e.g. training, consultations, project/build support, custom forms, external modules, or other Informatics help)
* must provide value
Yes No
View equation Fee Waiver Result based on your answers above
View equation CTSI office will review
REDCap Project Expiration Date
* must provide value
Today M-D-Y The project will not be accessed after the expiration date
View equation years (roundup) based on Expiration date entered above:
Cost per year (Lundquist investigator)
@HIDDEN-SURVEY 150
Cost per year (non-Lundquist investigator)
@HIDDEN-SURVEY 300
# of years: Sub total (Basic cost):
Cost per hour (Lundquist investigator)
@HIDDEN-SURVEY 75
Cost per hour (non-Lundquist investigator)
@HIDDEN-SURVEY 150
View equation Do you need purchase service hours (CTSI support such as Consultation or training by email/online/in person meetings, project build support, external module or any development assistance)? REDCap project development/assistance: If you need CTSI to help develop forms or assist with REDCap setup, please upload your file here: Enter estimate service/consultation hours you need to purchase ($75/hr TLI PI): (detail refer to the budget sheet) Sub total(Service cost):
Service/Special Functions Description (optional):
Sub total Service hour cost
View equation Do you need a quote on service hours needed?
Yes No
If you need quote, please specify service detail below.
We will create the forms in REDCap ourselves (self-service) We need CTSI support (QA or development assistance).
Upload forms(PDF or Word) need to be developed in REDCap
If there are multiple forms, please zip all the forms in one file and upload here.
Service hour purchase detail description if needed:
Enter service/consultation hours you need to purchase:
Refer to the above budget sheet or Contact lchen@lundquist.org for hours needed
View equation (CTSI waiver$ or voucher$) ( If Voucher, enter voucher app#/Date Upload approved voucher letter
enter the approved voucher/credit amount
e.g. CTSI voucher/date, HSOR Data Voucher
If this is a voucher, Please upload approved voucher letter for this project so we can apply the invoice amount.
View equation Estimate cost is based on the inforamtion currently provided in the form. Actual cost maybe different based on usage, service provided and functions added later on
If you don't have 10 digit project account# to transfer the fund, please indicate how are you going to pay for the charge.
If you don't have internal 10 digit account# and you plan to pay labiomed either via check or other external funding, your final cost will be different. Please contact CTSI office 310-222-2503 or gutierrez@lundquist.org .
Annual Renew rate (estimate-based on current annual rate+service hours)
(hidden)renew rate may change.
(hidden)
View equation for other institution (OH x1.541))
REDCap Data Protection (HIPPA)
REDCap End-User Agreement
By printing my name below, I certify that I have read and agree REDCap End-user Agreement.
* must provide value
Please download the user agreement above, Sign and upload the document here. (If you are not the PI or can not represent the PI, please download the user agreement above, pass the above information (such as cost, project deletion date...) to PI, get PI signature and upload the document here.)
Have you used REDcap before?
Yes No
Submit
Save & Return Later