Which of the following best describes why you are seeking a consultation?
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I have questions or need help with a specific project or grant proposal related to Dissemination and Implementation Research.
I have questions or need help with information about Dissemination and Implementation Research in general (e.g. career advice/mentorship, understanding Dissemination and Implementation research literature)
What is the working title of the grant or project related to your service request?
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Please provide some additional information about your dissemination or implementation project.
Background/significance [1 sentence]
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Intervention description, if applicable [1-2 sentences]
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Audience/setting [1 sentence]
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Potential outcomes [1-2 sentences]
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Implementation strategy, if known (e.g. practice facilitation) [1-2 sentences]
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Methods/approach [1-2 sentences]
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What type of consultation are you seeking? (Check all that apply)
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You indicated that you are seeking a consultation type other than those listed above. Please specify.
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Please list up to 4 questions you have for this consultation.
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What is the current stage of your project?
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Planning study
Applying for funding
Implementing funded study
Other (please specify)
You indicated that you are at a stage in the project other than those listed above. Please describe that stage here:
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Will this project be submitted for:
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External funding
Internal funding
Other (please specify)
I am not planning to submit this project for funding at this time
You indicated that you are applying for funding from a source other than an internal or external source. Please describe that source here.
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If you are planning to submit for external funding, please select all of the following institutes that you are planning to apply, if applicable. (Select all that apply)
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You indicated that you are applying to a funding agency other than those listed. What is the name of the organization?
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Does your project have a specific deadline?
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Yes
No
Please specify the date of the deadline.
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Today M-D-Y
We are generally able to schedule consultations within four weeks of the date of the request. If this time frame does not meet your needs, please provide additional information about your preferred timeline.
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What disease category or categories does your study involve? (Please select all that apply)
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You indicated that your research involves a disease category other than those listed. What is the disease?
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First Name
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Last Name
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Email address
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Phone number
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Please indicate all of your post-graduate degree(s).
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You indicated that you have an MD. Please describe your field/specialty.
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You indicated that you have a Ph.D. What discipline is the doctorate in?
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You indicated that you have a Master's Degree. What discipline is the Master's in? If you have more than one MS/MA, please describe them all.
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You indicated that you have a graduate degree other than those listed.
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Where are you currently conducting research? If you are not based at a university or organization listed, please indicate "other" and describe the institution.
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Albert Einstein College of Medicine Boston Children's Hospital Boston Medical Center Boston University Medical Campus Case Western Reserve University Children's Research Institute Columbia University Cornell University, Weill Medical Center Dartmouth Duke University Emory University George University Harvard University Icahn School of Medicine at Mount Sinai Indiana University J. Craig Venter Institute Johns Hopkins University Karolinska Institute, Sweden Mayo Clinic Medical College of Wisconsin Medical University of South Carolina New York University Northwestern University Ohio State University Oregon Health and Science University Pennsylvania State University Research Triangle Institute Rockefeller University Scripps Research Institute Seattle Children's Hospital Stanford University State University Of New York, Buffalo Tufts Medical Center Tufts University Boston University of Alabama, Birmingham University of California, Davis University of California, Irvine University of California, Los Angeles University of California, San Diego University of California, San Francisco University of Chicago University of Cincinnati University of Colorado Denver University of Florida University of Illinois, Chicago University of Iowa University of Kansas Medical Center University of Kentucky University of Massachusetts University of Miami School of Medicine University of Michigan, Ann Arbor University of Minnesota University of Missouri-Columbia University of New Mexico Health Science Center University of North Carolina, Chapel Hill University of Pennsylvania University of Pittsburgh, Pittsburgh University of Rochester University of Southern California University of Texas Health Science Center, San Antonio University of Utah University of Washington University of Wisconsin, Madison Vanderbilt University Vanderbilt University Medical Center Virginia Commonwealth University Wake Forest University Health Sciences Washington University Yale University Other organization (please specify)
You indicated you are conducting research at an organization not listed above. Please specify.
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What school or department do you work within at your institution (e.g., School of Medicine or Psychology department)?
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What is your current title?
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Assistant Professor
Associate Professor
Professor
Other (please specify)
You indicated you have a title other than those listed above. Please describe your title
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Which of the following best describes your level of experience conducting health research?
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Beginning (< 5 years)
Intermediate (5-10 years)
Advanced (>10 years)
Which of the following best describes your level of experience conducting dissemination and implementation research?
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Beginning (< 5 years)
Intermediate (5-10 years)
Advanced (>10 years)
List other team members. If you are not the principal investigator (PI), please note the PI or list "N/A" if not applicable.
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If applicable, what is the name of the D&I Core consultant that you are working with?
How did you hear about the UT Health San Antonio D&I Service Core?
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You indicated that you learned about our consulting service core from a source other than those listed above. Where did you learn about this service?
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Is there any additional information you would like to provide?
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