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Today's Date
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Today M-D-Y
Study Title
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Is this an Expedited Chart Review?
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No
What type of service are you requesting?
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Design Consult
Statistical Analysis
Data Request
Have you already discussed this project with a core member?
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Chiu, Yu-Fen Do, Huong Gripp, Kelsey Jannat-Khah, Deanna Jones, Agnes Lai, Emily Lan, Ranqing Nguyen, Joe Spivack, John Sun, Dongmei Wang, Shu-Han Wimberly, Audrey Zhu, Jiaqi
Additional Core member (if applicable)
Chiu, Yu-Fen Do, Huong Gripp, Kelsey Jones, Agnes Jannat-Khah, Deanna Lai, Emily Lan, Ranqing Nguyen, Joe Spivack, John Sun, Dongmei Wang, Shu-Han Wimberly, Audrey Zhu, Jiaqi
PI Department/Division/Service/Lab
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Anesthesiology and Pain Management ARJR Foot and Ankle Hand and Upper Extremity Infectious Disease Limb Lengthening and Complex Reconstruction Metabolic Bone Orthopedic Trauma Pathology and Laboratory Medicine Pediatric Orthopedic Surgery Pediatric Radiology and Imaging Pediatric Rheumatology and Perioperative Medicine Physiatry Primary Care Sports Medicine Radiology and Imaging Rehabilitation Rheumatology Scoliosis and Spine Sports Medicine and Shoulder Other
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Lila R. Baaklini, MD Jonathan C. Beathe, MD James D. Beckman, MD Devan D. Bhagat, MD Bradford E. Carson, MD Stephanie Cheng, MD Mary F. Chisholm, MD Kathryn DelPizzo, MD Christopher A. DiMeo, MD Naomi Dong, MD Chris R. Edmonds, MD Michael Friedman, MD Sean Garvin, MD Michael A. Gordon, MD Enrique A. Goytizolo, MD Douglas S.T. Green, MD Robert S. Griffin, MD, PhD Carrie R. Guheen, MD Semih Gungor, MD Stephen N. Harris, MD Stephen C. Haskins, MD Michael C. Ho, MD Joseph C. Hung, MD Kethy M. Jules-Elysee, MD Richard L. Kahn, MD Mandip S.Kalsi, MD David H. Kim, MD Sang Jo Kim, MD Richard H.S. King, MD Meghan A. Kirksey, MD, PhD Vladimir N. Kramskiy, MD Kanupriya Kumar, MD Vincent R. LaSala, MD Andrew C. Lee, MD David L. Lee, MD Gregory A. Liguori, MD Yi Lin, MD, PhD Jiabin Liu, MD, PhD Spencer S. Liu, MD Daniel B. Maalouf, MD, MPH Stavros G. Memtsoudis, MD, PhD John G. Muller, MD Jemiel A. Nejim, MD Joseph Oxendine, MD Jeffrey Y. Ngeow, MD Swetha R. Pakala, MD Leonardo Paroli, MD, PhD Christine Peterson, MD Thomas J. Quinn, MD, MBA Daniel I. Richman, MD James J. Roch, MD Nigel E. Sharrock, MB, ChB Ellen M. Soffin, MD, PhD Cephas P. Swamidoss, MD MPH Lauren Turteltaub, MD Michael K. Urban, MD, PhD William F. Urmey, MD Philip J. Wagner, MD Seth A. Waldman, MD David Y. Wang, MD Pamela K. Wendel, MD Douglas S. Wetmore, MD Jacques T. Ya Deau, MD, PhD Elaine I. Yang, MD Victor M. Zayas, MD Other
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Michael Alexiades, MD Michael P. Ast, MD Friedrich Boettner, MD Mathias P. Bostrom, MD Robert Buly, MD Alberto Carli, MD Charles N. Cornell, MD Michael B. Cross, MD Mark Figgie, MD Alejandro Gonzalez Della Valle, MD Steven B. Haas, MD Allan E. Inglis Jr., MD Seth A. Jerabek, MD David J. Mayman, MD Alexannder S. Mclawhorn, MD, MBA Bryan J. Nestor, MD Douglas E. Padgett, MD Michael L. Parks, MD Paul M. Pellicci, MD Amar S. Ranawat, MD Chitranjan S. Ranawat, MD Daniel S. Rich, MD Jose A. Rodriguez, MD Eduardo A. Salvati, MD Peter K. Sculco, MD Thomas Sculco, MD Edwin Su, MD Bradford S. Waddell, MD Geoffrey H. Westrich, MD Philip D. Wilson, Jr. MD Russell E. Windsor, MD Other
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Walther H.O. Bohne, MD Jonathan T. Deland, MD Constantine A. Demetracopoulos, MD Mark C. Drakos, MD Andrew J Elliott, MD Scott J. Ellis, MD Anne Holland Johnson, MD John G. Kennedy, MD David S. Levine, MD Martin J. OMalley, MD Matthew M. Roberts, MD Other
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Edward A. Athanasian, MD Michelle G. Carlson, MD Aaron Daluiski, MD Duretti Fufa, MD Robert N. Hotchkiss, MD Lana Kang, MD Steve K. Lee, MD Daniel A. Osei, MD, MSc Samir K. Trehan, MD Andrew J. Weiland, MD Scott W. Wolfe, MD Other
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S. Robert Rozbruch, MD Austin T. Fragomen, MD Other
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Charles N. Cornell, MD Joseph M. Lane, MD Other
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Gregory S. DiFelice, MD Duretti Fufa, MD David L. Helfet, MD Joseph M. Lane, MD Dean G. Lorich, MD John P. Lyden, MD William Ricci, MD Ernest L. Sink, MD David S. Wellman, MD Other
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Thomas Bauer,MD,PhD Manjula Bansal, MD Edward F. DiCarlo, MD Roberto A. Garcia, MD Michael J. Klein, MD Giorgio Perino, MD David Wuest, MD Yaxia Zhang, MD, PhD Other
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John S. Blanco, MD Aaron Daluiski, MD Emily R. Dodwell, MD, MPH, FRCSC Shevaun Mackie Doyle, MD Peter D. Fabricant, MD, MPH Daniel W. Green, MD, MS, FAAP, FACS Cathleen L. Raggio, MD David M. Scher, MD Ernest L. Sink, MD Samir K. Trehan, MD Roger F. Widmann, MD Other
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Eric Bogner, MD Alissa J. Burge, MD Li Foong Foo, MD, MRCP, FRCR Bernard Ghelman, MD Richard J. Herzog, MD, FACR Gabrielle P. Konin, MD Theodore T. Miller, MD, FACR Helene Pavlov, MD, FACR Hollis G. Potter, MD Gregory R. Saboeiro, MD Robert Schneider, MD Carolyn M. Sofka, MD Other
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Alexa B. Adams, MD Karen Brandt Onel, MD Nancy Pan, MD H. Susan Cha, MD Lisa S. Ipp, MD Thomas J.A. Lehman, MD Stephanie L. Perlman, MD Sarah Faith Taber, MD Other
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Ellen Casey, MD Vincenzo Castellano, MD Alice Chen, MD Paul M Cooke, MD Joseph H. Feinberg, MD Stephen G. Geiger, MD Jonathan S. Kirschner, MD, RMSK Emerald Lin, MD Christopher Lutz, MD Gregory E. Lutz, MD Elizabeth M. Manejias, MD Stepehn J. Massimi, MD Peter J. Moley, MD Rock Positano, DPM, MSc, MPH Joel M. Press, MD Kristina Marie Quirolgico, MD Faye Rim, MD, FAAPMR Alexander C. Simotas, MD Jennifer L. Solomon, MD James Wyss, MD, PT Vijay B. Vad, MD Other
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William W. Briner Jr., MD Lisa R. Callahan, MD John P. DiFiori, MD, FACSM Marci A. Goolsby, MD Brian C. Halpern, MD James J. Kinderknecht, MD Osric S. King, MD Ryan J Lingor, MD Jordan D. Metzl, MD Daphne A. Scott, MD Brett G. Toresdahl, MD David A. Wang, MD Warren K. Young Other
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Jennifer L. Berkowitz, MD Eric A. Bogner, MD Alissa J. Burge, MD John A. Carrino, MD, MPH Yoshimi Endo, MD Li Foong Foo, MD, MRCP, FRCR Christian S. Geannette, MD Harry G. Greditzer IV, MD Richard J. Herzog, MD, FACR Shari T. Jawetz, MD Gabrielle P. Konin, MD Susan Catherine Lee, MD Kevin R. Math, MD Darius P. Melisaratos, MD Theodore T. Miller, MD, FACR Douglas N. Mintz, MD Ogonna Kenechi Nwawka,MD Helene Pavlov, MD, FACR Hollis G. Potter, MD Robert Schneider, MD Elizabeth Schultz, MD Darryl B. Sneag, MD Carolyn M. Sofka, MD Other
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Alexa B. Adams, MD Juliet Aizer, MD, MPH Dalit Ashany, MD Anne R. Bass, MD Jessica R. Berman, MD Vivian P. Bykerk, BSc, MD, FRCPC Kamela Kim Chan, MD Mary K. Crow, MD Medha Barbhaiya MD, MPH Stephen J. Di Martino, MD, PhD, RhMSUS Doruk Erkan, MD, MPH David R. Fernandez,MD Theodore R. Fields, MD, FACP Allan Gibofsky, MD Susan M. Goodman, MD Jessica K. Gordon, MD Lionel B. Ivashkiv, MD Kyriakos A. Kirou, MD, DSc, FACP Lindsay S. Lally, MD Thomas J.A. Lehman, MD Alana B. Levine, MD Michael D. Lockshin, MD Theresa T. Lu, MD, PhD Carol A. Mancuso, MD, FACP C. Ronald MacKenzie, MD Steven K. Magid, MD Lisa A. Mandl, MD, MPH Joseph A. Markenson, MD Bella Mehta, MBBS, MD Charis F. Meng, MD Iris Navarro-Millan, MD Karen Brandt Onel, MD Stephen A. Paget, MD, FACP, FACR Nancy Pan, MD Edward J. Parrish, MD Linda A. Russell, MD Jane E. Salmon, MD Lisa R. Sammaritano, MD Sergio Schwartzman, MD Robert F. Spiera, MD Richard Stern, MD Hendricks H. Whitman III, MD, FACP, FACR Dee Dee Wu, MD Arthur M. F. Yee, MD, PhD Weijia Yuan, MD Other
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Todd J. Albert, MD John S. Blanco, MD Frank P. Cammisa Jr., MD Vincenzo Castellano, MD Alice Chen, MD Paul M. Cooke, MD Matthew Cunningham, MD, PhD James C. Farmer, MD Stephen G. Geiger, MD Federico P. Girardi, MD Charles B. Goodwin, MD Robert S. Griffin, MD, PhD Semih Gungor, MD Russel C. Huang, MD Alexander P. Hughes, MD Joseph C. Hung, MD Han Jo Kim, MD Darren R. Lebl, MD Christopher Lutz, MD Patrick F. OLeary, MD, FACS, PC Sheeraz Qureshi, MD, MBA Cathleen Raggio, MD Bernard Rawlins, MD Daniel I.Richman, MD Andrew A. Sama, MD Harvinder S. Sandhu, MD Frank Schwab, MD Alexander C. Simota, MD Jenifer L. Solomo, MD Seth A.Waldman, MD David Y. Wang, MD Roger Widmann, MD James F.Wyss, MD, PT Other
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Answorth A. Allen, MD David W. Altchek, MD Struan H. Coleman, MD, PhD Frank A. Cordasco, MD, MS Gregory DiFelice, MD Edward V. Craig, MD, MPH David M. Dines, MD Joshua S. Dines, MD Stephen Fealy, MD Andreas H. Gomoll, MD Lawrence V. Gulotta, MD Jo A. Hannafin, MD, PhD Anne M. Kelly, MD Bryan T. Kelly, MD John D. MacGillivray, MD Robert G. Marx, MD, MSc, FRCSC Michael J. Maynard, MD Moira M. McCarthy, MD Danyal H. Nawabi, MD, FRCS Stephen J. OBrien, MD, MBA Andrew D. Pearle, MD Anil S. Ranawat, MD Scott A. Rodeo, MD Howard Anthony Rose, MD Beth E. Shubin Stein, MD Sabrina M. Strickland, MD Samuel A. Taylor, MD Russell F. Warren, MD Thomas L. Wickiewicz, MD Riley J. Williams III, MD Other
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Name
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Name
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Name
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Name
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Name
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Email
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Primary Contact Information
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Preferred Email
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Would you like to add a secondary contact for this study? (optional)
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Secondary Contact Information (optional)
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What type of authorization do you have?
Institutional Review Board (IRB)
Proposal for Existing Registries (Form 5A)
Reviews Preparatory to Research
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Please upload your form
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What is your funding source?
Brief Description of Study
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Statistical Analysis Plan Template
Statistical Analysis Plan
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Other:
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What are you requesting these services for?
Is this the first analysis request for this study?
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What are you requesting these services for?
Where do you plan to submit or present your work?
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Where do you plan to submit this Analysis?
Today M-D-Y MM-DD-YYYY
Data Acquisition
Data Transformation
Which score would you like to have calculated?
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SF-12v1
SF-6D
VR-12
For VR-12 please use this template
For SF-12v1 or SF-6D please use this template
Do you have an approved 5A form?
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An approved 5A form is required for creating analytic datasets. In the absence of an approved 5A form, data can only be used for determining study feasibility.
Which HSS registry(ies) are you requesting data from?
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Which HSS registry(ies) are you requesting data from?
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Specific Aims
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Inclusion Criteria
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Exclusion Criteria
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Specific Data Elements
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