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Application for support

Please complete the following application form and submit. someone from the Clinical Informatics Research unit CORE team will then be in contact to discus this with you in more detail.

Richard Munday, Business Manager

Section 1 Key Contact Person
Please provide your contract details so that we can get in touch
Name *
Name
Address
Address
Section 2 Details of the Chief Investigator
If the Chief Investigator is the same as above please check
Name of Chief Investigator
Name of Chief Investigator
Chief Investigator Address
Chief Investigator Address
Section 3 BRC Support Required
Please fill in as much data as possible, don't worry if you are unsure about some of the questions we will talk this though with you later if we need clarification
If your from Southampton University or University Hospitals Southampton NHS foundation Trust and you think you re eligible for BRC Status then please tick the box.
Section 4 CORE Support required
Clinical database with CRF
Please Select an option if you not sure then let us know
Please indicate the number of data points your study might require
Please enter the number of CRF forms your study might have
Funding advice
Do you require any advice about funding for exsample what costs are needed to put into an application for Data management support
Data managment
do you need support in writing a data management plan or need support with data management once the study is running
Randomisation
Do you need a tool to randomise patients into the study
Drug supply system
Do you need tools to manage the supply of drug within the study
ePRO
An electronic patient-reported outcome is a patient-reported outcome that is collected by electronic methods. ePRO methods are most commonly used in clinical trials, but they are also used elsewhere in health care.
Statistics
You require some statistical support in the design or analysis of the study
Translation of eCRF or ePRO
We have a in house translators as well as access to external teams that can help you translate your study into other languages. If you need help with this then please let us know
Writing proticol assistance
You require the CORE team to support you writing the protocol or even the application form
Please specify in as much detail, we might have other parts of the team that can support you
Is this part of your PhD or other qualification?
Can you let us know how you knew that we provided these types of services
Section 5 Research Proposal Outline
Please provide as much detail as possible.
Please enter this in months
Proposed start date
Proposed start date
What is your proposed start date
What is the proposed sample size
Section 6 Statistics
which organisation is the Statistician from e.g Southampton
Please provide a email address as a min
Section 7 Funding
Do you already have funding for this project
if your answer is yes then please continue to complete Section 7.1 if your answer it not then please continue to Section 7.2
Section 7.1 Agreed Funding
Please complete this section if you have funding
£
e.g University Hospitals Southampton NHS foundation Trust
Please provide details of award cost centre from you financial team e.g. Agresso Number
Section 7.2 funding to be determined
Please complete this section if you are applying for funding
for exsample NIHR, MRC, HTA
Deadline for application
Deadline for application