Purpose of this project: Other:
Today M-D-Y
View equation View equation 2024 2025 2026 2027 2028 2029 2030
Purpose of this project:
* must provide value
Research Clinical Care QI Operations Other (Please specify)
How many sites? Planned # of subjects? Collect PHI? Duration of Project(Yrs) Intention of Publication? Industry Initiated?
Yes No
Yes No
Intention of publication?
Yes No
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
Requester: Email: -Phone: Dept: -Postion: Institution: -Other:
PI Name: PI email: Is PI/co-PI a current Lundquist investigator ? Is the PI/co-PI a Fellow, Resident or Junior investigator ?
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?
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.
Estimate # of REDCap users: 1. Please list users' Full Name and Institution Email (prefer Lundquist email). Due to security issue, try not to enter personal email such as gmail or yahoo here) 2. Please indicate the person who can design the database. 3. 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.
xAre you going to create project based on an existing XML file?
Yes No
Requester name
* must provide value
Last, First
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
UserimportTemplate file upload
Estimate # of REDCap users
REDcap users - Who need to and can access this REDCap project? 1. Please list users' Full Name and Institution Email (prefer Lundquist email). Due to security issue, try not to enter personal email such as gmail or yahoo here)
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.
Institution
* must provide value
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
Cost Charge Account (e.g. 10 digit project account#)
For Lundquist/Harbor UCLA, Please enter your 10 digit project account
Proposed or Actual Funding amount $
Is the PI/co-PI a Fellow, Resident or Junior investigator?
* must provide value
Yes No
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
Yes No
xWhat'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
IRB#: IRB Approved? Approve Date: Expiration Date:
If this is a DHS research project, select DHS Category:
Have you select use CTSI and REDCap in your IRB application?
Yes No Will do N/A
click on "i" for more information
Yes No In process N/A
Today M-D-Y
Today M-D-Y
File Attachment (*upload IRB approved letter if available)
DHS Research Category Assigned by CMO/Designee:
N/A 1 2 3 4 5 99 Pending
REDCap has basic hosting fee per project per year: $150(Lundquist)/$300(non-Lundquist). Service can be purchased: $75/hr(Lundquist)/; $150/hr(non-Lundquist)
*REDcap baisc hosting fee per Year per Project: $150(Lundquist); $300(non-Lundquist) **Consultation service/hour: $75/hr(Lundquist)/; $150/hr(non-Lundquist) lchen@lundquist.org ) or CTSI office (Gutierrez, Raquel: gutierrez@lundquist.org) 310-222-2503 Do you have funding support including Dept. support to pay REDCap cost? Funding status: Funding agency/source: Estimate or Actual Funding amount (fundamt} Cost Charge Account (e.g. 10 digit project charge account#)
* If you don't have project charge account#, please specify how are you going to pay the invoice
REDCap Project Expiration Date
* must provide value
Today M-D-Y
View equation years (roundup) based on Expiration date entered above:
Cost per year (Lundquist investigator)
@HIDDEN-SURVEY 150
Cost per year (non-Lundquist investigator)
@HIDDEN-SURVEY 300
# of years: Sub total (Basic cost):
Cost per hour (Lundquist investigator)
@HIDDEN-SURVEY 75
Cost per hour (non-Lundquist investigator)
@HIDDEN-SURVEY 150
View equation Do you need a quote on service hours? REDCap Form development: If you need us to develop the form in REDCap, please upload file: Enter service/consultation hours you need to purchase: Sub total(Service cost): Initial fee: Other cost:
Initial setup or service description if needed:
Sub total Service hour cost
View equation Do you need a quote on service hours needed?
Yes No
If you need quote, please specify service detail below.
We will create the forms in REDCap ourselves (self-service) We need CTSI staff to create the forms for us (full service)
Upload forms(PDF or Word) need to be developed in REDCap
If there are multiple forms, please zip all the forms in one file and upload here.
Initial setup or Service description if needed:
Enter service/consultation hours you need to purchase:
Contact lchen@lundquist.org for hours needed
View equation (CTSI Credit$) ( Voucher Name/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
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