This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range.

The value you provided is outside the suggested range.

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

NYMpioSDh365nzqmh5tLj8urLjhTtIHKJThv3YBSBztLV39aHjKVv5CZ6mup7rydnCmSxy7FeqaiozuzBCiTDVBfBkRgRjbAQZoUWLKUCFHmP5P3jumSFpJU

Research Monitor Visit Request

Returning?

A A A

Welcome!

Use this online form to request access to UT Health San Antonio's instance of EpicCare Link for Research Sponsor's monitors.

Remote and On Campus visits involving access to Epic
Requests can only be made by UTHealthSA research team members
As a general rule, requests should be submitted at least 30 calendar days before the visit start date.

What information do you need to complete the request form?

Basic study information (CTMS number*, title, etc.)
Monitor's information (name, email, whether a current EpicCare Link user)
Coordinator/Data Manager's information & EpicCare Link permissions
Monitoring start and end dates
Copy of monitor's visit request (letter, email or optional form)

* The study must be registered in Velos eResearch - contact the CTO for assistance.

Save & Return - see the instructions at the bottom of the form on how to save your work and return later to complete the submission.

Security -- This questionnaire uses UT Health San Antonio's instance of REDCap. REDCap is a secure web authentication application that is HIPAA compliant. Access is through centralized two factor authentication, all data are encrypted meeting FISMA security standards, physical, network, and computer security is third-party monitored and enforced through the university's Information Assurance Division.

Cancer Related Research?

* must provide value

Cancer Related Research

Non-Cancer Research

reset

Request Type

* must provide value

New Visit

Change dates of scheduled visit

Setup EPIC research account

Assign Coordinator role

Remove Coordinator role

Link Coordinator to study

Remove Coordinator from study

Remove Monitor from study

Suspend Monitor's ECL access

reset

UTHSA Employee Information

Name*

UTHSA email*

Is the study being monitored registered in Velos?

* must provide value

Yes

reset

Warning!
The study must first be registered in Velos before proceeding with this request.

Please follow these instructions:
-- Fill out the "Study Information" table below (insert N/A in the CTMS # field)

-- Click "Save & Return Later" button at the bottom of the page. Record the "return code" for future use.

What happens next? The VPR CTO will be notified and contact you to register the study in Velos.

Insert the Study Information originally submitted.

Study Information

CTMS #*		UTHSA PI
Study Title

Has a Research account previously been set-up in EPIC for this study?

* must provide value

Yes

reset

UTHSA Coordinator Information

Name*

UTHSA email*

Does ______ have an Epic account?

* must provide value

Yes

reset

Warning!
The Coordinator/DM must have an Epic account to proceed with this request.
For information regarding Epic access, go to:
https://uthealthsa.sharepoint.com/teams/UTHealth-EpicCare/SitePages/Training-Documents-Library.aspx

Is ______'s EpicCare account connected to this study?

* must provide value

Yes

reset

Has ______ been granted special permission for managing monitor visits in EpicCare Link?

* must provide value

Yes

reset

Insert the Monitor Information originally submitted, do not change the monitor.

Monitor's Information

First Name*		Last Name*
Employer		Email*

What are the original visit dates that you wish to change?

Original Start

Original End

Insert the new start and end dates in the Visit Information table below

Visit Information

Type*
Start Date*		End Date*

Note: The start date is ______ days from today.

In general, we like to receive these requests at least 30 days prior to the start date.

Please continue - we will try to approve this request in time.

WARNING:

Your start date is ______ days from today.

Monitoring visits should be submitted at least 30 days prior to the start date.

According to the information provided above, this appears to be a complicated request, requiring several administrative steps and will likely take require the full 30 days.

Important Information

Your on-site visit request is for ______ consecutive days.

Additional security measures including a background check are required for on-site visits longer than three days.

You have two choices:

Continue as planned, understanding the background check must be completed before EPIC access can be granted, OR
Change the date range to three or less consecutive days.

STOP! Your remote visit request is for ______ consecutive days.

Remote visits longer than five days are not allowed. Please adjust your dates in order to proceed.

Is ______ ______ a current UTHSA EpicCare Link user?

* must provide value

Yes

reset

Has ______ ______ previously monitored this study (______) using UTHSA EpicCare Link?

* must provide value

Yes

reset

Upload a copy of the monitor's request

Upload file

Our optional request form (PDF) is available to download and share with the monitor.

Attachment:

Research Monitor Visit Request Form PDF.pdf

Save & Return
You do not have to complete the form in one session.
To save your work and return later, click on the "Save & Return Later" button located at the bottom of each page.

Two Important Steps when using Save & Return
To return to the survey, you will need both the Survey Link and your Return Code.

Return Code is required, please write down the value

Survey Link
You may bookmark this page to return later,
-or-
You can have the survey link emailed to you by providing your email address in the space provided

DateDiff

View equation

Number of Days:

View equation

Date Dif Today - Start Date

View equation

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.