Table 4.
Registry Data Request Form
| Questions | Response Options |
|---|---|
| Demographics | |
| Name of PI | Text 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. | |